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661. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.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

662. CHIPRA 209 Report: Neonatal Intensive Care Outcomes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-209-fullreport.pdf
     June 01, 2019 - BPD: gentle ventilation strategies, including primary use of continuous positive airway pressure (CPAP … Continuous distending pressure for respiratory distress in preterm infants. … Impact of bronchopulmonary dysplasia, brain injury, and severe retinopathy on the outcome of extremely

663. Experiences From the Frontline: Case Studies (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/frontline-cases-studies.pdf
     May 01, 2015 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) revealed … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased by … 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 to

664. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - As Tucker has noted, production pressure may cause health care professionals to participate in “first-order … improving patient safety: “We have been analyzing and creating reports of falls with and without injuries

665. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
     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.

666. HF Measures For Public Comment (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0084maternity.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

667. HF Measures For Public Comment (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0082maternity.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

668. Maternity Care Performance Measurement Set (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/CHIPRA-BMI-Maternity-Care-Measures.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

669. HF Measures For Public Comment (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternity.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

670. HF Measures For Public Comment (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternitycare.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

671. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
     January 01, 2024 - that patients with diagnosis-related claims were 2.33 times more likely to die than to have a minor injury … and have been associated with increased medical errors and stress, anxiety, and burnout.113,114 Time pressure … diagnostic safety found the need to prioritize research on system factors, such as workload, time pressure … Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from … Adv Wound Care (New Rochelle). 2013 Dec;2(10):588-592. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3865615

672. Making Informed Consent an Informed Choice: (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/audio-script-healthcare-professionals-training.pdf
     January 18, 2017 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don’t think I could forgive myself if he wound up dying of meningitis because we didn’t finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent

673. Improving Hospital Inpatient Nursing Care: A Case Study of One Hospital's Intervention to Improve the Patient's Care Experience (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/compare/WR_751_AHRQ_Quigley_08_26_10.pdf
     April 01, 2010 - There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … • Don’t let initial pushback from stakeholders or external pressures derail QI efforts; stay focused … specialized intensive care units, state-of-the-art inpatient and outpatient operating suites, a Level-1 trauma … There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … medical doctor referrals to hospital specialists • Hospital workforce data o Vacancy rate o Workplace injuries

674. Diagnostic error in mental health: a review (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
     April 15, 2024 - Despite the importance of effective data gathering and synthesis, time pressures, competing priorities … J Trauma Dissociation 2017;18:233–47. 31 Sheehan DV, Lecrubier Y, Sheehan KH, et al. … procedures: are diagnosticians influenced by the narrative fallacy when assessing the psychological injuries … of trauma victims Psychol Inj Law 2016;9:265–71. 54 Jenkins MM, Youngstrom EA.

675. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/corbett.html
     August 01, 2017 - An adverse event is defined as an injury resulting from health care management, rather than the underlying … from a rural hospital recommended “Organize the paperwork with separate categories to clearly define ‘wound

676. Making Informed Consent an Informed Choice: Training for Health Care Professionals Audio Script | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
     September 01, 2020 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don't think I could forgive myself if he wound up dying of meningitis because we didn't finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent form

677. PowerPoint Presentation: Learn From Defects Through Sensemaking
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     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.

678. Hospital Survey on Patient Safety Culture: User's Guide (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/userguide/hospitalusersguide.pdf
     July 01, 2018 -  “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 … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking

679. Department of Health and Human Services National Institutes of Health - National Institute for Research on Safety and Quality (NIRSQ) (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cpi/about/mission/budget/2021/FY_2021_CJ_NIRSQ.pdf
     January 01, 2021 - Rounds on the Web); • AHRQ QuestionBuilder App; • AHRQ’s Safety Program for Nursing Homes: On-Time Pressure … scans ordered, higher physician trust, and higher patient knowledge in cases involving minor head injuries