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401. Hospital Survey on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.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

402. Chapter 5. Information and Training for Staff, Primary Care Providers, and Residents and their Families | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man5.html
     December 01, 2017 - (number of falls, number of fallers, number of residents with 2 or more falls and number of serious injuries … Use Low Blood Pressure Precautions

403. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
     January 01, 2024 - brought it to the forefront of public attention.1 The IOM report estimated that more than a million injuries … that many patients annually are injured as a result of medications.3;4 Furthermore, many of these injuries … developing systems that prevent and buffer errors, we gathered information about the types and causes of injuries … The most common injuries resulting from ADEs were cardiovascular, especially hypotension, defined as … a systolic blood pressure less than 90 mm Hg (40%), and metabolic derangements, such as severe hypoglycemia

404. 018-Revision-Summary-Contact-Precautions (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/018-revision-summary-contact-precautions.docx
     October 01, 2024 - contact, changes in care that contribute to delays and non-infectious adverse events (e.g., falls, pressure … injuries), increased symptoms of depression and anxiety, and decreased patient satisfaction.16 · Adverse

405. Final Progress Report: A National Report of Nursing Home Quality Measures and Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/alexander-report.pdf
     January 01, 2024 - daily living has increased; 2) who have moderate to severe pain; 3) who are at high risk and have pressure … sores; 4) who are at low risk and who have pressure sores; 5) who are physically restrained; 6) who … the percentage of residents 1) with delirium; 2) who have moderate to severe pain; 3) and who have pressure … Symptoms 14168 797 5.6 5.1 Who Were Physically Restrained 14203 798 0.9 0.7 One or More Falls with Major Injury … Physically Restrained -0.02 -0.02 0.01 0.01 0.01 0.01 0.01 0.00 -0.02 0.00 One or More Falls with Major Injury

406. Final Progress Report: Developing Best Practices for Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/baker-report.pdf
     January 01, 2024 - delivery of hospital care.14 15 16 17 18 19 By some estimates, as many as a half million preventable injuries … preventable deaths may occur each year, at a cost estimated to exceed $30 billion per year.20 Most of these injuries … evidence on the effectiveness and cost of comprehensive patient safety programs for reducing avoidable injuries … Production pressure in the work environment: California anesthesiologists' attitudes and experiences … Production pressure in the work environment: California anesthesiologists' attitudes and experiences

407. Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
     January 01, 2025 - compounded in the emergency department (ED) by a hazardous decision-making environment fraught with time pressure … data-driven studies of infectious disease diagnostics performance,9,10 in-depth study of acute kidney injury … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a … Optimal Acute Kidney Injury Algorithm for Detecting Acute Kidney Injury at Emergency Department Presentation … Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department

408. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
     September 28, 2016 - private-public partnerships to: • Identify the causes of preventable health care errors and patient injury … approximately $19.8 billion in health care costs were saved from 2010 to 2014 Adverse Drug Events Pressure … • Unsafe care causes 43 million injuries a year and the loss of 23 million disability- adjusted

409. Making Effective Changes in Antibiotic Decision Making (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
     November 01, 2019 - His heart rate is 100 beats per minute, and his blood pressure is normal at 121 over 75. … This could have prevented the development of acute kidney injury or AKI, and additional laboratory … Using one of the areas of harm, acute kidney injury from unnecessary vancomycin, let’s consider how

410. Serious Reportable Adverse Events in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
     December 01, 2000 - Excludes deaths resulting from self- inflicted injuries that were the reason for admission to the health … Stage 3 or 4 pressure ulcers acquired after admission to a health care facility Excludes progression … Death or significant injury of a patient or staff member resulting from a physical assault (i.e., … Adverse describes a negative consequence of care that results in unintended injury or illness, which … A No fault for medical injury: theory and evidence.

411. 007-Ss-Contact-Precautions-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/007-ss-contact-precautions-fg.docx
     April 01, 2025 - safety and safe injection practices to minimize the risk of infection transmission and needle stick injury … care equipment between patients – which in the pre-op area and PACU may mean equipment such as a blood pressure … Staff also reported feeling pressure to expedite transport by skipping steps in the contact precautions

412. Overuse of Imaging for the Evaluation of Children with Simple Febrile Seizure: Final Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-192-fullreport.pdf
     November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system injury, and … • Signs or symptoms of increased intracranial pressure (Table 10 [=IMG11]; see Supporting Documents … • Signs or symptoms of increased intracranial pressure. • Abnormal neurologic exam. … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … Incidental findings in children with blunt head trauma evaluated with cranial CT scans.

413. Appendix III (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiid.html
     June 01, 2010 - A few are related to the health and welfare of clients, such as injuries and medication errors. … HCBS MS Domains: Unmet Need Populations: Individuals with disabilities, adults with acquired brain injuries … information concerning the number of incidents (abuse and neglect; restraints, crimes against, serious injuries … required data via NCI form titled "NCI Protocol for Reporting Incidents: Abuse and Neglect, Serious Injuries … additional measures under development relate to influenza vaccinations for people with disabilities and pressure

414. Appendix D. Falls Engineer Instructions | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapd.html
     December 01, 2017 - Engineer Instructions The Falls Management Program is designed to prevent falls and injuries … Fill to the pressure recommended on the side of the tire. … Instructions: If the brake lever does not bite 1/8 inch into the tire, it may be because the tire pressure

415. Usability Testing and the Relation of Clinical Information Systems to Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
     January 01, 2003 - Scenario-based testing also identified workplace performance trade-offs related to time and production pressures … ability to identify impact prior to implementation and to suggest redesign before adverse events or injury … Difficulty in design decisions can more easily be created when “typical” work with its time pressure … a series of often unrelated single tasks (e.g., open a program, save a file), without performance pressure … Software used in health care can prevent patient injury or contribute to it, when usability testing

416. Financial and Demographic Influences on Medicare Patient Safety Events (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
     January 01, 2004 - Database for Florida from 1996–99 (373,814 discharges at 188 hospitals) to examine whether financial pressure … Shen (2003) examined the effect of financial pressures on patient outcomes and found that financial … pressures adversely affect patient outcomes.7 That study used data from an earlier period (1985–94), … The effect of financial pressure on the quality of care in hospitals. … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

417. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - With disease, injury, or illness, the diagnosis is often obvious and may involve no more than simple … Coercive pressures may drive a particular agenda that is not congruent with good decisionmaking. … For example, team pressures to lower door-to-needle times for thrombolytic therapy in the context of … affective error by changing systemic features: decreased reliance on memory, minimization of time pressure … Minimize time pressures Provide adequate time for quality decisionmaking.

418. Final Progress Report: Evaluating the Impact of Simulated Team Training on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
     January 01, 2024 - Use the ambulatory surgical setting as a model to better understand risks and injuries and to focus … University of Michigan, complications may occur in nearly 13% of cases.4 Preventable healthcare-related injuries … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … by the team; and 3) Hypercarbia – the patient becomes hypercarbic with increased peak inspiratory pressures … and implement team training curricula regarding other domains, such as rare event crises in the OR, trauma

419. Error Producing Conditions in the Intensive Care Unit (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
     February 26, 2008 - Time pressure in error detection. 3. Low signal-to-noise ratio. 4. … percent), the surgical ICU (8 percent), the neurological critical care unit (8 percent), and the burn-trauma … 38 ICU workplace (%) Medical 68 Thoracic 12 Surgical 8 Neurological critical care 8 Burn-trauma … Given the problems outlined above, it is no surprise to find that under time pressure, the operation … Preventing ventilator-related death and injuries.

420. Screening for Family and Intimate Partner Violence: Systematic Evidence Review (pdf file)
     www.ahrq.gov/downloads/pub/prevent/pdfser/famviolser.pdf
     March 01, 2004 - Inflicted injury versus accidental injury. [Review] [87 refs]. … Validation of a Trauma Questionnaire in veteran women. … Analytic Framework and Key Questions *Including physical trauma (fractures, dislocations, brain injury … If answer is yes, code “1” for no injury, “2” for possible injury, and “3” for injury. … 6 = Use of weapon, wound from weapon 4.