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421. Urine Culturing Stewardship in the ICU Setting Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
     April 01, 2022 - Her temperature is 100.8 degrees Fahrenheit, heart rate 130, respiratory rate 22, and blood pressure … mistakenly considered an unavoidable “cost of doing business” instead of understood as avoidable, tragic injury

422. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
     March 26, 2008 - leading cause of patient harm is medication errors, which account for almost 20 percent of medical injuries … .1 Twenty-eight percent of medication-related injuries (adverse drug events, ADEs) are considered preventable … Anesthesia Patient Safety Foundation (APSF) notes a significant, underappreciated risk of serious injury … with other medication errors, IV infusion programming errors have a greater likelihood of causing injury … programmed, appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure

423. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
     August 01, 2023 - Identification of children at very low risk of clinically-important brain injuries after head trauma: … Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury … Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE … Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. … The use of telemedicine in the care of the pediatric trauma patient. Semin Pediatr Surg .

424. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
     January 01, 2024 - Results: Major hazards identified included time pressure, lack of coordination between physician and … hazards. 18,19,33 3 It is well recognized in safety engineering that the heart of safety lies not in injuries … A hazard is anything that increases the probability of errors or of patient/ employee injury and is … -Sutures removed too soon after minor surgical procedure and wound dehiscence, which requires 6 weeks … Patient gets dizzy after first dose, falls, but no injury and stops med.

425. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
     January 01, 2024 - Only half of basic care processes are provided as recommended, and injuries due to medical errors (preventable … electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries … Conclusions: In hospital-related settings, implementing CPOE is associated with >50% decline in patient injuries … Cost Implications of Improving Blood Pressure Management among U.S. Adults.

426. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
     January 01, 2025 - states, however; for example, abuse incidents are taken very seriously, but falls, other incidents, and pressure … events or medication errors; resident altercations or other types of abuse; and non-fall related injuries … Compared to 38.5% surveyor visits for burns and 22.7% for pressure ulcers, the numbers are fairly low … The relationship between physical restraint removal and falls and injuries among nursing home residents … ., dispensing, administration, adverse drug event) 27 17.3 6.3 69.3 7.1 24 12.5 4.2 66.7 16.7 Pressure

427. Documentation of Heart Rate During Fluid Resuscitation for Children With Severe Sepsis or Septic Shock (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-fullreport.pdf
     June 01, 2018 - (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for treating underlying injury once shock is present. … , central venous pressure, urine output, metabolic status, and peripheral perfusion (Rooney, Nadel, … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the

428. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/049-dec-implementation-slides.pptx
     October 01, 2024 - and Dressings8 Recommended for superficial wounds Friable skin/rashes Superficial burns Pressure injuries … Recent nasal surgery or trauma: Discuss with your hospital’s ENT surgeons to establish guidelines for … CHG is approved as a wound cleanser. … Encourage wound care nurses to provide support to staff who are uncomfortable. … SHIELD: Eliminating Multidrug-Resistant Organisms; FAQ: Wound Care.

429. Primary Care Practice Facilitation Curriculum Module 31: Facilitating Panel Management (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-31-facilitating-panel-management.pdf
     September 01, 2015 - acute care centers—services rendered to patients needing urgent medical attention (e.g., infection, injuries … The registry can also identify patients not in control of HbA1c, LDL, or blood pressure, patients who … Other information may need to be input by someone in the clinic, for example, blood pressure, weight … The Panel Manager may also have the job to enter data into the registry (like blood pressures) and to … Which of these patients would you call to schedule a group blood pressure clinic appointment? b.

430. 7.  Appendix C: Additional Tables by Topic Area | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
     May 01, 2024 - Appendix D: Grant Summaries P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … program that supports patients discharged from the hospital to home after an episode of acute kidney injury … Prioritizing Quality Improvement for the Treatment of Psychiatric Disturbances Following Traumatic Brain Injury … support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure … practice facilitation would improve the use of a hypertension-focused CDS to effectively improve blood pressure

431. Unique Challenges in Approaching Diagnostic Safety in Older Adults | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
     September 01, 2024 - presented 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

432. Implement-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
     May 01, 2017 - 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, Leadership, Information … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60/40

433. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/index.html
     July 01, 2022 - Reige Surveillance Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM … Song, Tracey Pritchett Developing a Veterans Health Administration (VHA) Serious Injury Surveillance … Jaser, Nancy Safer, Paul Davern Medical Injury Identification Using Hospital Discharge Data (   PDF … Nozick Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure

434. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
     January 01, 2024 - Physicians already felt pressure to reduce or limit time with patients to meet scheduling demands and … outpatient treatment, unplanned admission or readmission, or emergency room visit), or new physical injury … In contrast, the nature of most errors was equipment injuries (23%), diagnostic delays or failures ( … Medical errors leading to complaints included medication errors (n=5), equipment injuries (n=3), diagnosis … and dollar amounts Patient complaints were more likely than errors to result in some new physical injury

435. Final Progress Report: Implementing Reduced Work Hours for All House Staff To Improve Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/landrigan2-report.pdf
     January 01, 2024 - begin their work day 8-10 hours after awakening (86), leaving them with more accumulated homeostatic pressure … (i.e., injuries from needle sticks and scalpel laceration), and ‘fall-asleep’ incidents. … extended-duration shifts compared to non-extended-duration shifts. (99) In addition, the odds of a needlestick injury … A computer alert system to prevent injury from adverse drug events. JAMA 1998;280(1317):1320. … Extended work duration and the risk of self-reported percutaneous injuries in interns.

436. Improving Safety Using Teamwork and Patient Safety Norms (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
     June 30, 2025 - Implementation of TeamSTEPPS at a Level-1 Military Trauma Center: The San Antonio Military Medical … hospital-acquired infection was reviewed using LFD ► LFD used for post-fall huddle and after skin injury … Skin: Pressure Ulcer? POA? - Current descript ion of PU 10. Foley: Can it be removed?

437. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
     March 01, 2016 - Staffing, Work Pressure, and Pace ................................ 4 Composite 4. … Effective Crisis Management Living a Culture of Patient Safety Policy and Brochure Medically Induced Trauma … Staffing, Work Pressure, and Pace 1. … portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury … Staffing, Work Pressure, and Pace Composite 4. Teamwork Composite 5. Staff Training Composite 6.

438. Emergency Nurses Association content and transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/ena-slides.pdf
     September 01, 2015 - Need for resources • What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery  Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds  Consult with the wound care

439. Emergency Nurses Association content and transcript (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ena-slides.pdf
     September 01, 2015 - Need for resources • What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery  Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds  Consult with the wound care

440. Labor and Delivery Unit Safety: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
     July 01, 2023 - Intrauterine pressure catheter or fetal scalp electrode placement. Manual rotation. … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.