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361. Building a Team and Process to Reduce CAUTI Risk (April 8, 2015) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/building-teamwork-transcript.html
     December 01, 2017 - The fourth indication is the healing of open wounds that are close to the groin area. … , such as a motor vehicle accident where they have an injury to the spinal cord. … Assisting healing with a perineal or sacral wound in certain patients. … or multiple traumatic injuries, such as multiple fractures, and you worry that, again, movement will … Wound care nurses, we talked about, the pressure associated with the Foley catheter is helping.

362. 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.

363. Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/research/grants-2022.html
     August 01, 2025 - Use of ChatGPT for Urinary Symptom Management Among People With Spinal Cord Injury or Disease: Qualitative … evidence, diagnostic practices, and outcomes for the problems of unintentional weight loss, high blood pressure … clinical problems above, based on analysis of EHR data; existing evidence, including from a home blood pressure

364. Healthcare Safety Competencies Affinity Group Environmental Scan (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/healthcare-safety-competency-environmental-scan.pdf
     March 27, 2025 - including central line-associated bloodstream infections, ventilator-associated events, hospital-acquired pressure … injuries, patient falls, and catheter-associated urinary tract infections during the COVID-19 pandemic … Bureau of Labor Statistics, in 2018, healthcare workers accounted for 73% of all nonfatal workplace injuries … Safety Science- Adjacent • Workload Management • Burnout • Worker Safety • Fatigue • Moral Injury … The Human Experience • Burnout • Co-Design • Fatigue • Improving Access to Care • Moral Injury

365. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
     January 01, 2025 - preventable.6-9 Numerous factors, such as increasing acuity, limited data for decision making, time pressures … We queried home medications, chief complaint, triage data such as acuity and trauma leveling, keywords … BiPAP – bilevel positive airway pressure; CPAP – continuous positive airway pressure; D50 – 50% Dextrose … (11%), and pressure ulcers (12.3%). … hypoxia and hypotension, delirium/ confusion, various bleeding events, surgical complications and injuries

366. Improving Patient Safety in Long-Term Care Facilities: Training Modules (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
     June 01, 2012 - safety, create a more resident-centered environment, and reduce the number of falls and fall-related injuries … In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury … use to reduce the number of falls. › Nursing staff must have the knowledge and skills to prevent injury

367. Survey on Patient Safety (facility version) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
     June 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

368. Safe Practices for Better Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
     April 01, 2004 - Not surprisingly, health care errors and consequent adverse events are a leading cause of death and injury … Introduction Health care errors and consequent adverse events are a leading cause of death and injury … Evaluate each patient upon admission, and regularly thereafter, for his or her risk of developing pressure … contrast media-induced renal failure, and use a clinically appropriate method for reducing risk of renal injury … Use of specialized hospital flooring to reduce injury from patient falls. 3.

369. Hospital Survey on Patient Safety (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
     June 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

370. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
     January 01, 2005 - 519, mandates that all manufacturers of medical devices must report device-related deaths, serious injuries … facilities” must report medical device related deaths to FDA and to the manufacturer and report serious injuries … of medical devices so it could become more proactive in addressing device issues before a death or injury … the various types and sizes of facilities that are obligated to make reports of deaths and serious injuries … systems are really at the root of the problem, and c) clinicians report they are just too busy with the pressures

371. Mod5-Comm-Assessment (pdf file)
     www.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

372. Appendix VII: Public Comments Submitted Between March 7 and March 21, 2008 (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apviia.html
     June 01, 2010 - of State Directors of Developmental Disabilities Services, the National Associations of State Brain Injury … agencies, units on aging, agencies serving individuals with physical disabilities, traumatic brain injury … Medicaid-eligible individuals who are frail and elderly, have intellectual and developmental disabilities, head injuries … of State Directors of Developmental Disabilities Services, the National Associations of State Brain Injury … future and the "Never Events," I did not see any use of the never events, including: Stage 3 or 4 pressure

373. Envisioning Patient Safety in the Year 2025: Eight Perspectives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Henriksen_104.pdf
     January 01, 2025 - Patients are fully compensated for all costs of injuries; we provide emotional support for patients … Forum), and requires health care organizations to compensate patients for costs of treatment-related injuries … management and facility model will be paired with a regionally centralized system of critical and trauma … support consumer groups to assure authenticity, to accelerate progress in patient safety through public pressure … episodes—necessarily resulting from the variegated and heterogeneous nature of human physiology, of illness and injury

374. 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/

375. 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

376. 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

377. Strategies to Better Engineer Safety into Healthcare Delivery (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
     March 06, 2025 - that make it more difficult for people to make errors in care delivery or experience a work-related injury … designed to reduce the transmission of healthcare-associated infections and the risk of occupational 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

378. Final Progress Report: Bridging the Gap between EMS and Health Services Research: A Conference for Researchers and Practitioners (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/delia-kutzin-report.pdf
     January 01, 2025 - For example, the Brain Trauma Foundation periodically updates its hyperventilation guideline for the … Impacts of quality reporting in EMS may be driven more by peer pressure and regulation. Dr. … Friedrich von Recklinghausen presented information about the Trauma and EMS Information System (TEMSIS … Other applications involve local epidemiology of injury and demand for EMS services. … Because EMS remains a low-profile issue, researchers feel pressure to “bury” EMS in other projects with

379. 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.

380. 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.