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221. Communication: Obstetric Hemorrhage - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3_communication.pptx
     July 01, 2023 - interruption to a doctor who is with a patient's family members. 2 Maternal and Perinatal Deaths and Injuries … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are— Assessment (i.e., the adequacy, … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift.” 

222. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/index.html
     April 01, 2025 - as pressure injury) from exposure to intense and/or prolonged pressure, moisture, friction, and shear … ’s achievements include the creation of a digital bedside display that shows patients’ catheter and wound … injuries (formerly called ‘pressure ulcers’). … injury) and rhythmic motion (for detection of seizure). … Respiratory failure (oxygen saturation, partial pressures of oxygen and carbon dioxide, mode of respiratory

223. Appendix B. Clinical Materials to Share With Primary Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb.html
     December 01, 2013 - supplementation, mechanical ventilation, air leaks, pulmonary edema, PDA ligation, infection causing lung injury … Blood pressure: Not higher in infants with nephrocalcinosis, but overall higher in preterm infants … Should have: Blood pressure checked at every visit. … diarrhea are at risk for zinc deficiency and may need supplementation: Poor growth, diarrhea, impaired wound

224. The National Action Alliance to Advance Patient Safety Summer Webinar Series - PowerPoint Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/public-action-alliance-slides-040323_LOCKED.pdf
     May 25, 2023 - factors focus areas • Workplace Change Collaborative – National Framework on Burnout and Moral Injury … “By and large, the U.S. does not account for medical care injuries and deaths in our vital statistics … Where it should say 'medical care harm/injuries', it's blank. … as surge … our new normal *Healthcare Acquired Infections, Early Elective Deliveries, Falls with Injury … , Healthcare Acquired Pressure Injuries, NTSV C-Section patients to get to WHO Goal, Sepsis Mortality

225. Care Coordination Quality Measure for Primary Care (CCQM-PC) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/cati-script.pdf
     July 01, 2016 - able to walk a flight of stairs without losing your breath, or target rates —for example, a blood pressure … In the last 12 months, if you had an illness or injury, how often did your primary care provider or … professionals in this office ask whether you had enough services to help you take care of this illness or injury … NEEDED] 1 Never 2 Sometimes 3 Usually 4 Always, or 5 I did not have an illness or injury … High blood pressure or hypertension? 66e. Congestive heart failure? 66f.

226. Survey on Patient Safety (facility version) (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
     April 02, 2025 - · “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

227. Comparison Tables for Making Healthcare Safer Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
     January 01, 2025 - (Not reviewed) (Not reviewed) (Not reviewed) Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence (all patients) (Not reviewed) (Not reviewed) Preventing Patient Death or Serious Injury … Summary of Evidence Summary of Evidence (all patients) (Not reviewed) (Not reviewed) Prevention of Pressure

228. Transitioning Newborns from NICU to Home: Family Information Packet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/nicupacket.pdf
     December 01, 2013 - ■ Should have: – Blood pressure checked at every visit. … diarrhea are at risk for zinc defciency and may need supplementation: – Poor growth, diarrhea, impaired wound … ■ BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay. … – Bivona ■ Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures … – Gastric or esophageal trauma during placement.

229. Transitioning Newborns from NICU to Home: Family Information Packet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket.pdf
     December 01, 2013 - ■ Should have: – Blood pressure checked at every visit. … are at risk for zinc deficiency and may need supplementation: – Poor growth, diarrhea, impaired wound … – Bivona ■ Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures … – Set suction pressure between 80-100 mmHg. … – Gastric or esophageal trauma during placement.

230. Technical Appendix | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tap.html
     December 01, 2012 - in a 1915(c) for aged and disabled people; aged people only; disabled people only; people with brain injuries … , 758.31, 758.33, 758.39, 758.7, 759.5, 759.81-759.83, or 759.89), developmental delay-severe brain injury … who are under age 65 and are not classified as I/DD or SMI (includes, for example, traumatic brain injury … Prevalence of high blood pressure, State's . … "Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure

231. Survey on Patient Safety (facility version) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     April 02, 2025 - • “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

232. Hospital Survey on Patient Safety (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
     April 02, 2025 - · “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

233. Implement Teamwork and Communication for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-fac-guide.html
     July 01, 2023 - Slide 6: Root Causes of Maternal and Perinatal Deaths and Injuries 2004-2012 Say: Human factors … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are— Assessment. … Example: The nurse says to the doctor, "Doctor, the patient's blood pressure is dropping; it is 60/

234. Part 1: Overviews of the Report and the Hispanic Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part1.html
     March 01, 2020 - For example, only half of people with high blood pressure have it controlled. … Leading causes of morbidity and mortality include heart disease, cancer, unintentional injuries, stroke

235. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
     April 02, 2025 - • “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

236. 018-Revision-Summary-Contact-Precautions (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/018-revision-summary-contact-precautions.docx
     October 01, 2024 - contact, changes in care that contribute to delays and non-infectious adverse events (e.g., falls, pressure … injuries), increased symptoms of depression and anxiety, and decreased patient satisfaction.16 · Adverse

237. Chapter 5. Information and Training for Staff, Primary Care Providers, and Residents and their Families | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man5.html
     December 01, 2017 - (number of falls, number of fallers, number of residents with 2 or more falls and number of serious injuries … Use Low Blood Pressure Precautions

238. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - private-public partnerships to: • Identify the causes of preventable health care errors and patient injury … approximately $19.8 billion in health care costs were saved from 2010 to 2014 Adverse Drug Events Pressure … • Unsafe care causes 43 million injuries a year and the loss of 23 million disability- adjusted

239. Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
     January 01, 2025 - compounded in the emergency department (ED) by a hazardous decision-making environment fraught with time pressure … data-driven studies of infectious disease diagnostics performance,9,10 in-depth study of acute kidney injury … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a … Optimal Acute Kidney Injury Algorithm for Detecting Acute Kidney Injury at Emergency Department Presentation … Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department

240. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Identification of children at very low risk of clinically-important brain injuries after head trauma: … Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury … Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE … Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. … The use of telemedicine in the care of the pediatric trauma patient. Semin Pediatr Surg .