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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - · “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts
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ce.effectivehealthcare.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
January 01, 2024 - Antidepressant
treatment and suicide attempts and self-inflicted injury in children and adolescents. … Antidepressant treatment
and suicide attempts and self-inflicted injury in children and adolescents … also
investigate our strategy’s impact on intermediary clinical outcomes, including systolic blood pressure … measures included medication understanding, adherence, and clinical measures (hemoglobin A1c,
blood pressure
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
October 01, 2018 - per 1,000 instrument-assisted deliveries
• Birth trauma - injury to neonate per 1,000 selected live … 40
60
80
100
2014 2015 2016 2017 2018 2019 GOAL
Ra
te
p
er
1
,0
00
D
is
ch
ar
ge
s
Pressure … 40
60
80
100
2014 2015 2016 2017 2018 2019 GOAL
Ra
te
p
er
1
,0
00
D
is
ch
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s
Pressure … Adverse Drug Events
• An adverse drug event (ADE) is an injury—including physical harm, mental harm, … The home health team should regularly change wound dressing and teach the patient about
wound care.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm7.html
October 01, 2014 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … self-reporting is an invalid and unreliable way to collect data on clinical indicator values, such as blood pressure … Blood pressure test at every continuing care visit. … A State interested in tracking pressure ulcers in its Supplemental Security Income (SSI) population, … contains hybrid specifications for measures such as cholesterol management, controlling high blood pressure
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
April 01, 2004 - Not
surprisingly, health care errors and consequent adverse events are a leading cause
of death and injury … Introduction
Health care errors and consequent adverse events are a leading cause of death
and injury … Evaluate each patient upon admission, and regularly thereafter, for his or her risk of
developing pressure … contrast media-induced renal
failure, and use a clinically appropriate method for reducing risk of renal injury … Use of specialized hospital flooring to reduce injury from patient falls.
3.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - If someone is in danger of injury or an emergent procedure is missing a vital resource, we do what needs … Were decisions made under pressure, despite distractions, or without appropriate knowledge of case or
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ce.effectivehealthcare.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
September 01, 2013 - Wound Care
1. For what types of wounds is chlorhexidine (CHG) application safe? … to avoid causing additional soft tissue
damage or extension of the wound due to pressure against the … #2: Nasal Trauma
Do NOT use mupirocin if nostril(s) are packed. … CHG will not harm occlusive dressing (e.g., wound vacs).
Do NOT use on large or deep wounds … CHG can cause
permanent injury if it comes in direct contact with nerves and is allowed to remain there
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Lavelle_33.pdf
March 12, 2008 - related to pediatrics, respiratory emergencies,
and seizures, the urgent care staff also requested trauma … scenarios (e.g., lacerations, fractures,
head injuries, spinal cord injuries). … to obtain a more easily
transportable, moderate-fidelity manikin with heart/lung sounds and blood pressure
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/sppc-summary_report.pdf
May 01, 2017 - Rate-Injury to Neonate
o Obstetric Trauma Rate-Vaginal Delivery
With Instrument
o Obstetric Trauma … Rate-Injury to Neonate (AHRQ Patient Safety Indicator 17)
• Obstetric Trauma Rate-Vaginal Delivery … With Instrument (AHRQ Patient Safety Indicator 18)
• Obstetric Trauma Rate-Vaginal Delivery Without … , they sustained the use of TeamSTEPPS
tools and techniques through peer support and positive peer pressure … • More favorable changes in the obstetric trauma with instruments measure (PSI 18) for units
with
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/f1-returnoninvestment.pdf
January 01, 2009 - For example, improvement actions might reduce
hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries
during hospitalization
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
June 01, 2023 - record systems have clinical decision support that can be helpful in flagging triggers (e.g., low blood pressure … Tidal volumes of 6–8 mL/kg of predicted body weight with positive end expiratory pressures of 5 cm H2O … approach:
Intraoperative tidal volume 6–8 mL/kg of predicted body weight with positive end expiratory pressures … All ISCR Pathways
Wound Protector Use
Recommended approach:
Wound protectors are recommended for all … is drinking liquids unless the patient has difficulty with oral intake, there is evidence of kidney injury
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
January 01, 2013 - For example, improvement actions might reduce
hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries
during hospitalization
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
December 01, 2022 - state-specific data on preventive health
practices and risk behaviors linked to chronic diseases, injuries … The
examination includes physical measurements, such as blood pressure and dental examinations,
and … from each family in the house and collects data on topics including
health status and limitations, injuries … patient’s age, gender, race,
and ethnicity; patient’s expressed reason for visit; intentionality of injury … ulcer adverse events Pressure Ulcer
Venous thromboembolism/pulmonary embolism (VTE/PE)
not related
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
December 01, 2023 - state-specific data on preventive health
practices and risk behaviors that are linked to chronic diseases, injuries … from each family in the house and collects data on
topics including health status and limitations, injuries … patient’s age, gender, race,
and ethnicity; patient’s expressed reason for visit; intentionality of injury … include mode of arrival, waiting time,
duration of time in the ED, initial vital signs, and cause of injury … ulcer adverse events Pressure Ulcer
Venous thromboembolism/pulmonary embolism
(VTE/PE) not related
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/crane.html
August 01, 2017 - 59 percent
Information exchange with other settings
49 percent
53 percent
54 percent
Work pressure … Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ulep.pdf
January 01, 2004 - dealing with falls, medication
safety, lab specimen safety, identification problems, and employee health injuries … Ever-increasing
budget pressures often lead to staffing cuts, causing overburdened employees to
develop
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
December 01, 2017 - reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … It’s tough when the pressure is high and the patient is at risk.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
January 01, 2003 - as increased
medication-borrowing behavior to avoid citations for “drug not
available” or the time pressures … Assessing patient safety risk
before the injury occurs: an introduction to socio-
technical probabilistic
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - Root cause analyses of adverse
events and near-misses (events that did not produce
patient injury) … The AHRQ Patient Safety Indicator
18 (Obstetric Trauma–Vaginal Delivery with Instrument)
decreased … in-house
neonatal death, uterine rupture during labor, unplanned maternal admission
to ICU, birth trauma … processes at the
point of care to include specific maternal parameters,
including blood loss, blood pressure … They established a standard process
for blood pressure measurement upon admission and
during labor