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321. 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/ccqm-pc-survey-instructions.pdf
     July 01, 2016 - most of your usual health care needs and who you normally see when you need care for a new illness or injury … being 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 … 1 Never 2 Sometimes 3 Usually 4 Always 5 I did not have an illness or injury in the last … High blood pressure or hypertension? Congestive heart failure? Coronary artery disease?

322. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.pdf
     January 01, 2023 - An example of additional detail from the Fall module would be the type of injury sustained in a fall … Pressure Ulcers result in harm to the patient by their very nature. … This is unexpected, as pressure ulcers result in harm to the patient by their very nature. … unstageable • A lesion that, on admission, was a suspected Deep Tissue Injury • A pressure ulcer … Pressure Ulcers result in harm to the patient by their very nature.

323. Final Progress Report: Safety in the Home Healthcare Sector: A Pilot Study (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/gershon-report.pdf
     January 01, 2024 - Nearly one of four RNs (19%, n=142) reported experiencing an injury in the past 3 years. … The majority of these injuries were back injuries, (n=68, 48%), upper-extremity injuries (n=38, 27%) … , and lower extremity injuries (n=37, 26%). … Of those with a fire extinguisher, only two households had a fire extinguisher with a working pressure … Childhood injury prevention at home and play.

324. Improving Patient Safety in Long-Term Care Facilities, Module 1 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ltcmodule1.pdf
     June 01, 2012 - She has high blood pressure, diabetes, and arthritis. She is also being treated for depression. … pressure ulcer (bed sore) if not responded to promptly. … 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

325. Communication Assessment Guide: Appendix 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/ap2.html
     August 01, 2022 - 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

326. Appendix B. Clinical Materials to Share With Primary Care Providers (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
     December 01, 2013 - BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay. … Vent frequently to prevent gas pressure from compromising the seal. … 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.

327. Appendix B. Clinical Materials to Share With Primary Care Providers (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/packet/apb2.html
     December 01, 2013 - BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay. … Vent frequently to prevent gas pressure from compromising the seal. … 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.

328. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-196-fullreport.pdf
     January 01, 2020 - children with secondary headaches accompanied by neurological signs or symptoms of increased intracranial pressure … in blood pressure; and/or irregular heart rhythms (Society for Pediatric Anesthesia, 2014). … headache in the absence of documented neurologic signs or symptoms that suggest increased intracranial pressure … , new neurologic deficits, or signs and symptoms of increased intracranial pressure may require timely … Incidental findings in children with blunt head trauma evaluated with cranial CT scans.

329. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/vaesurveillance-slides.pptx
     January 01, 2017 - Best Practices for VAE Reduction RECOMMENDATION INTERVENTION Basic practice Use noninvasive positive pressure … probiotics Ultrathin polyurethane endotracheal tube cuffs Automated control of endotracheal tube cuff pressure … complications through fluid conservation Protect against atelectasis by managing sedation Combat acute lung injury

330. Making Health Care Safer II, Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
     March 01, 2013 - “common;” examples include falls, venous thromboembolism (VTE), potential adverse drug events, or pressure … The scope must also consider the severity of each event; for instance, most falls do not result in injury … patient safety target, such as adverse drug events, or general clinical topics, such as preventing pressure … High (hypoglycemia) Low-to- moderate NA Interventions to prevent contrast-induced acute kidney injury … Common/ Moderate High Moderate (bleeding) Low Little/Moderate Preventing patient death or serious injury

331. Overuse of Computed Tomography Scans for the Evaluation of Children with a First Generalized Afebrile, Atraumatic Seizure: Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-fullreport.pdf
     November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system (CNS) injury … • Neurologic signs of increased intracranial pressure. … sedation, moderate and deep sedation carry a greater risk of airway compromise, hypoxia resulting in CNS injury … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … ; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury

332. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - Data are gathered about the type of event, the location of the event, contributing factors, injuries … • Ensure there are no reprisals for reporting of errors and injuries, both actual occurrences and … of particular importance because all team members must be prepared to move quickly to prevent such injury … There has been a 36 percent reduction in the pressure ulcer rate since July 2006. … The number of patient falls with injury per 1,000 inpatient days is one of the core clinical indicators

333. Communication: Obstetric Hemorrhage (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
     July 01, 2023 - 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. … 2023 Communication Obstetric Hemorrhage Communication is… Maternal and Perinatal Deaths and Injuries

334. Ed-Catheter-Insertions-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.doc
     September 10, 2013 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.

335. Lessons in Safety Climate and Safety Practices from a California Hospital Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Singer.pdf
     April 01, 2003 - This heightened interest has increased pressure on hospitals to reduce medical errors. … Increased regulatory and payer pressures have encouraged hospital leaders to undertake efforts to improve … For example, one consortium participant from a large multihospital network created an injury graph that … Based on this analysis, she categorized injuries by hospital. … The visual image helped motivate the organization to set system goals for reducing patient injuries.

336. Module 3. Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mgdod3.html
     October 01, 2014 - In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Develop participants' knowledge and skills in preventing falls and fall-related injuries. … He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury

337. Emergency Department and Catheter Insertion | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
     December 01, 2017 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.

338. 2022 National Healthcare Quality and Disparities Report Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-final-es.pdf
     October 01, 2022 - injury deaths), followed by accidental falls and motor vehicle accidents (each of which accounted for … approximately 20% of unintentional injuries) … an important cause of death that disproportionately affects younger populations, was unintentional injury … • Among the top 10 causes of YPLL, rates of unintentional injury, heart disease, liver disease, and … eclampsia/preeclampsia rate, which measures a complication of pregnancy characterized by high blood pressure

339. Final Progress Report: Health Journalism 2011, national conference on healthcare journalism (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/bruzzese3-report.pdf
     January 01, 2024 - Soldiers with traumatic brain injuries. Athletes with concussions. … care o From pee wee to pro: Head injuries in sports o Can the FDA ensure food safety? … Journalism Graduate Program • How nanotechnology may revolutionize the detection of traumatic brain injury … interim deputy director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury … "Sim Man" and "Harvey" reproduced physiological signs, such as blood pressure and heart and breathing

340. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - percent).5 In terms of overall numbers, preventable technical complications of surgery (10,891) and wound … Postoperative wound dehiscence 15. Transfusion reaction Treatment 5. … Birth trauma and obstetric trauma (3 types related to delivery methods) Preventive 10. … as “response generalization.”36 This line of OBM research informed an intervention to decrease injuries … individual access to computers; d) adding clinical decision support; e) instigating relevant peer pressure