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161. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
     August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

162. How To Manage Change
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_slides_fallprev.pptx
     August 24, 2017 - Process Change process strategies can be applied to other quality improvement efforts: Hospital-acquired pressure … injuries Catheter-associated urinary tract infections Deep vein thrombosis or pulmonary embolism following

163. Webinar 6: Enhance Services for High-Risk Patients | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/resource/guide/web6.html
     December 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

164. Hospital Survey on Patient Safety (doc file)
     healthcare411.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

165. Mod5-Comm-Assessment (pdf file)
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
     April 01, 2016 - Eventually, they are able to re-establish a normal heart rate, blood pressure, and adequate blood oxygen … During her procedure, her heart rate, blood pressure, and oxygen level were monitored. … During a part of the procedure, we became aware that her heart rate, blood pressure, and oxygen level … First off, right now Mary is stable; her heart rate, blood pressure, and oxygen level are all in normal … We also don’t know right now if she has suffered any injury from what happened, but we will check her

166. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
     August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

167. Hospital Survey on Patient Safety (pdf file)
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
     December 22, 2017 - • “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

168. Best Practices in Fall Prevention
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
     June 16, 2017 - number of medications that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … Carefully assess patients for any injuries in a systematic way.

169. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
     August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

170. Defining the New AHRQ: A Race for 21st Century Care | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/news/blog/ahrqviews/defining-new-ahrq.html
     January 01, 2021 - HAC events amount to more than $28 billion in excess healthcare costs, including pressure ulcers ($9.9 … nurses and other healthcare professionals remains a significant and troubling issue, as do workplace injuries

171. Tool 5: How To Conduct a Postdischarge Followup Phone Call | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
     March 01, 2013 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI

172. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The event review focuses on uncovering latent hazards or contributing factors that increase pressure

173. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
     May 01, 2017 - fetal criteria for procedures that increase risk for cord prolapse47 such as— amniotomy intrauterine pressure … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

174. Labor and Delivery Unit Safety: Slide Presentation | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
     July 01, 2023 - Intrauterine pressure catheter or fetal scalp electrode placement. Manual rotation. … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

175. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - The term safety refers to reducing risk from harm and injury, whereas the term quality suggests striving … Information Form, and Summary of Initial Report Form) and then applying Common Formats for falls, pressure

176. Advancing Patient Safety | Agency for Healthcare Research and Quality
     healthcare411.ahrq.gov/patient-safety/reports/advancing/index.html
     July 01, 2022 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

177. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
     January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home

178. Module 2: How To Manage Change (doc file)
     healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_fall-prevention.docx
     August 24, 2017 - applied to other quality improvement efforts in a hospital, such as preventing: Hospital-acquired pressure … injuries.

179. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
     healthcare411.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

180. 2017Qdr-Patsafchartbook (pdf file)
     healthcare411.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 ar ge 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.