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381. 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

382. 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

383. 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

384. 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

385. 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

386. 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

387. 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.

388. 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

389. 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/

390. 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

391. 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

392. 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

393. 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

394. Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture: Webcast Transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/ascwebcast0715_transcript.pdf
     September 01, 2015 - our overall efforts in patient safety, and as part of the National Action Plan for health-associated injuries … Smith, Slide 23 And the area with the most room for improvement was Staffing, Work Pressure and Pace … Smith, Slide 25 The two bottom-performing items were from Staff Training and the Staffing, Work Pressure … And you can see that for Staffing, Work Pressure and Pace it was a 94 percent positive compared to a … Brown, Slide 44 Our second area of focus was Staffing, Work Pressure and Pace, and our result was 55

395. Final Progress Report: Weekend Effects and the July Phenomenon in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/weissman-report.pdf
     January 01, 2024 - The PSIs identify “birth trauma” in low-risk births with documentation of hypoxic injury, nerve injuries … , and several other types of injuries. … It is known that anesthesiologists have been effective at identifying factors, such as production pressure … anesthetic poisoning AND active drug dependence, active nondependent abuse of drugs, or self-inflicted injury … (N) Inc: liveborn infants Exc: infants w/subdural or cerebral hemorrhage, pre-term infants, injury

396. 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

397. 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

398. 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.

399. 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.

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