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261. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=8
     January 01, 2024 - Publication Date: March 2015 Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Coordination, Health Information Technology and Health Information Exchange, Human and Environmental Factors, Pressure … Information Exchange Publication Date: December 2014 Communication To Prevent and Respond to Medical Injuries

262. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-slides.html
     September 01, 2017 - showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure … DNR,DNH, MOLST, or POLST Order in Place Oxygen Therapy Catheter or Ostomy Present Stage II or > Pressure … Gastrointestinal/ Genitourinary Symptoms Endocrine/ Metabolic/ Nutrition Issues Wound … Genitourinary Endocrine/ Nutritional/ Metabolic Musculoskeletal/ Joint Symptoms Wound … Circulatory Problems Hypertension or Renal Failure Gastroenteritis Angina Pectoris Falls /Trauma

263. Engineering Safe Practices Affinity Group | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/engineering-safety-practice/index.html
     September 01, 2025 - that make it more difficult for people to make errors in care delivery or experience a work-related injury … Healthcare Settings includes strategies to identify risks and hazards and prevent/control work-related injury … Healthcare-Associated Infections Program (contains multiple resources and toolkits). * Preventing Pressure

264. Final Progress Report: Risk and Recovery in Complex Environments: Labor and Delivery as a Model (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/goldman2-report.pdf
     January 01, 2025 - constraints impact the coordination and delivery of care, and patients suffer unexpected complications and injuries … sequence of preceding events, the specific end states that are modeled can range from a specific patient injury … Blood pressure regulatory functions are modeled as a subsystem of both the mother and the fetus. … A common initiating event or failure is blood pressure lability that can ultimately lead to one or more … Risk is perhaps best depicted as a dynamic situation in which two events – progression to injury and

265. Central Venous Catheter Indications and Alternatives Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives-notes.docx
     April 01, 2022 - They are as follows: · Stage III or stage IV or unstageable pressure ulcers · Moderate to severe incontinence-associated … Intermittent catheterization is often used in patients with neurogenic bladder or spinal cord injury, … urinary retention with or without bladder outlet obstruction · Stage III or stage IV or unstageable pressure … ulcer, or similarly severe wounds of other types, that cannot be kept clear of urinary incontinence … despite wound care and other urinary management strategies, if the ISC is adequate to manage the type

266. Outcomes by HCBS Participant Characteristics | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find5.html
     December 01, 2012 - higher rates on all measures other than Short-Term Complications of Diabetes, Bacterial Pneumonia, and Pressure … The exceptions are Pressure Ulcer, which is effectively equal in urban and nonurban areas, and Infection … Rates for women in the Medicaid-only population are always higher than for men except in Pressure Ulcer … The main exception to the county-level age pattern is the Pressure Ulcer measure, for which rates are … The pattern is strong for all conditions except high blood pressure.

267. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-ref.html
     May 01, 2023 - Costs of venous thromboembolism, catheter-associated urinary tract infection, and pressure ulcer. … The costs of medical falls by component of cost, timing, and injury severity. … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … Ostomy Wound Manage . 2016 Nov;62(11):30-8. 65. Mendizabal A, Thibault DP, Willis AW. … Marginal hospital cost of surgery-related hospital-acquired pressure ulcers.

268. On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
     September 01, 2024 - common individual adverse events for populations with sufficient size for analysis were: 1) worsening pressure … injuries that were present on admission (2021: 4.9 percent, 2022: 6.0 percent), 2) hypoglycemic events

269. TeamSTEPPS® Diagnosis Improvement: Module 5 Situation Monitoring To Improve Diagnosis - Facilitator’s Notes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-presenters-notes.pdf
     January 10, 2022 - It also ensures staff are supported in times of stress or production pressures or when the day is just … or unfolding error An opportunity to interrupt or correct an action or event before harm or injury …  and  teams  to  take  steps  to  interrupt  or  correct  an  action  or  event  before  harm  or  injury … Are the blood pressure cuffs, otoscope, ophthalmoscopes, and other equipment working properly? … Are things being left undone because of time pressure?

270. Module 5: Situation Monitoring
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module5-situation-monitoring.pptx
     January 10, 2022 - It also ensures staff are supported in times of stress or production pressures or when the day is just … allows individuals and teams to take steps to interrupt or correct an action or event before harm or injury … risk or unfolding error An opportunity to interrupt or correct an action or event before harm or injury … Are the blood pressure cuffs, otoscope, ophthalmoscopes, and other equipment working properly? … Are things being left undone because of time pressure?

271. Standardized Simulated Events for Provocative Testing of Medical Care System Rescue Capabilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blike.pdf
     January 01, 2003 - Elimination of sedation errors is particularly important since associated deaths and neurological injuries … review of 90 pediatric sedation- related critical incidents resulting in death or severe neurological injury … This report has served as a warning that pediatric patients are at especially high risk for injury during … They initially took over positive pressure ventilation. … Assumed RN had optimized positive pressure ventilation.

272. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
     January 01, 2014 - Video: Do Less Harm 2 Presentation Goals Highlight the gap between optimal response to medical injury … Resolution) process and how this toolkit will help organizations improve their response to medical injury … The nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … field of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … helps them care for their patients. 36 Module 1 In addition to the organization Medically Induced Trauma

273. Mod01-Grand-Rounds-Slides (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
     April 01, 2016 - Say: Today’s Presentation Goals are to: ■ Highlight the gap between optimal response to medical injury … the CANDOR process and how this toolkit will help organizations improve their response to medical injury … nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … Slide 35 Say: In addition to the organization Medically Induced Trauma Support Services (or MITSS)

274. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - Say: Today's Presentation Goals are to: Highlight the gap between optimal response to medical injury … The nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … Slide 12 Say: The response to medical injury involves more than just what to do and what … field of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … Slide 35 Say: In addition to the organization Medically Induced Trauma Support Services

275. Chartbook on Black Health Care: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/qdr-blackhealth-slides.html
     November 01, 2020 - Infant mortality per 1,000 live births (more than 2,499 grams) Worse No Change Birth trauma—injury … Slide 75 Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2013 Image … : Chart shows birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2013: … Trends: From 2004 to 2013, birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.

276. Reducing the Use of Short-acting Nifedipine by Hypertensives Using a Pharmaceutical Database (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Furmaga.pdf
     January 01, 2005 - initiated efforts to decrease the common but unapproved use of that agent for treating high blood pressure … Further concern was raised regarding the use of short-acting nifedipine for rapid reduction of blood pressure … nifedipine that, while allowing for some uses (e.g., autonomic dysreflexia secondary to spinal cord injury … were continued (158 [9.5 percent] for treatment of autonomic dysreflexia in patients with spinal cord injury … acting nifedipine for hypertension, 84 (15 percent) for autonomic dysreflexia secondary to spinal cord injury

277. On-Time Preventable Hospital and Emergency Department Visits (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
     November 30, 2013 - • Current clinical conditions contributing to transfer risk: use of oxygen, catheter or ostomy, any pressure … and skin, injury (fall related or not fall related), musculoskeletal, abnormal labs or anemia, fever … or skin issues • Fall-related injury • Non-fall-related injury • Abnormal labs • Fever/possible infection … disease • Asthma • Circulatory problems • Hypertension • Gastroenteritis • Angina pectoris • Falls/trauma … obstructive pulmonary disease, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls/trauma

278. Session 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html
     October 01, 2014 - Reddened or darkened skin near a pressure point, or skin breakdown in those areas, can lead to a full … pressure ulcer (bed sore) if not responded to promptly. … whether it is an observed and assisted transition to the floor or an unwitnessed event that results in an injury … Vital Signs Vital signs include temperature, respiratory rate, blood pressure, and pulse rate. … Residents are safest—protected from harm or injury—when everyone expects to openly report anything that

279. Table 13C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13c.html
     December 01, 2012 - Composite: ACSC Overall 16,190 13,777 11,837 15,406 12,890 12,089 11,728 15,849 Pressure

280. Table 13F: HCBS Population Ages 18-64 Without I/DD or SMI | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13f.html
     December 01, 2012 - Composite: ACSC Overall 25,088 21,726 18,033 23,910 21,388 17,059 17,977 25,619 Pressure