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281. National Healthcare Quality And Disparities Report Patient Safety Chartbook (pdf file)
     www.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.

282. Sustainability: Learning From Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-fac-notes.html
     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

283. QDR 2014: Chartbook for Hispanic Health Care, Part 3 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pdf
     June 01, 2014 - less likely than privately insured Hispanic adults to receive needed care right away for an illness, injury … Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes … 50 P e rc e n t Total White Black Hispanic Adults who needed care right away for an illness, injury … Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure

284. Final Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
     January 01, 2025 - primary complaint of fall occurring within the previous 48 hours; were not categorized as a level 1 trauma … Nurses described challenges with teach back, including time pressure for both themselves and patients … info organized logically, important info on front page • Useful info in AVS (e.g., info on home care (wound … care partner during D/C • ED physician/ APP talking with pt about D/C before ED nurse • Time pressure … Preventable medical injuries in older patients. Arch Intern Med. 2000;160:2717-2728. 14.

285. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-care-coordination.pdf
     June 01, 2024 - Illinois R36 HS23072 [Grant] Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Report Purpose: To examine the influence of nurse continuity on the prevention of hospital- acquired pressure … the dynamic changes in risk and understand the frequency that human attributes and organizational pressures … As hospitals face increasing financial constraints, the pressure to favor productivity and throughput … examine transition of care factors that contribute to risk and hazards associated with iatrogenic injury

286. Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
     January 01, 2020 - peripheral vascular complication [including pseudoaneurysm, hematoma at catheter insertion site, vascular injury

287. 2021 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-datasources.pdf
     December 31, 2021 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, 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 … 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

288. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
     www.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

289. Fallspximpl-Handouts (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.docx
     April 02, 2025 - The On-Time reports may also take some of the pressure off communication practices by automatically providing … She did make a recommendation for a medication change and some increased monitoring of blood pressure

290. 2019 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
     December 01, 2020 - 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 … infections; seven types of adverse events associated with surgery; patient falls; and hospital-acquired pressure … events associated with the hospital stay and not present on hospital admission (inpatient falls and pressure

291. Ambulatory Safety and Quality Program: Health IT Portfolio (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ambulatory-safety.pdf
     July 01, 2010 - protocol using an EHR to identify patients in need of treatment intensification for systolic blood pressure … treatment device and an internet-based portal that tracks management of continuous positive airway pressure … Focus Area(s): Drug-induced injury in the ambulatory geriatric population Type of Health IT: EMR Principal

292. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/handout.html
     November 01, 2017 - The On-Time reports may also take some of the pressure off communication practices by automatically providing … She did make a recommendation for a medication change and some increased monitoring of blood pressure

293. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - 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

294. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pptx
     September 19, 2015 - 2014 White Black Hispanic 89.3 86.5 82.2 Percent Adults who needed care right away for an illness, injury … less likely than privately insured Hispanic adults to receive needed care right away for an illness, injury … 18.100000000000001 18.899999999999999 20.2 Percent Children who needed care right away for an illness, injury … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … Achievable Benchmark: 70.7% Importance: Many patients who receive home health care are recovering from an injury

295. 043-Vap-Prevention-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/043-vap-prevention-notes.docx
     October 01, 2024 - Cancer and trauma patients are also at a higher risk of developing VAP than other populations. … These include high-flow oxygen or noninvasive positive pressure ventilation (NIPPV). … Patients who have suffered a stroke or other neurologic injury are those that come to mind most often

296. Return on Investment Tool (doc file)
     www.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

297. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_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

298. 43-Pathway-Worksheet (doc file)
     www.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

299. State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-older-adults.pdf
     January 17, 2024 - to his physical therapist 23 days after falling off a ladder, resulting in a mild traumatic brain injury … Lamjoun, et al. (2023)39 Normal pressure hydrocephalus and mania symptoms: case report A 54-year-old … e.g., registered nurses, clinical pharmacists, social workers, nutritionists) and face institutional pressure … Normal pressure hydrocephalus and mania symptoms: case report. … against overtesting, overdiagnosis, and overtreatment of older adults: thinking beyond imaging and injuries

300. Return on Investment Tool (pdf file)
     www.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