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441. AHRQ Transforming Primary Care Grants | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
     May 01, 2015 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385 The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure

442. AHRQ Transforming Primary Care Grants Bibliography | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/grants-transform/bibliography/index.html
     February 01, 2017 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385 The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure

443. Safety Climate on Hospital Units: A New Measure (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
     January 01, 2004 - Studies have identified a number of factors that affect the rate of worker injury. … authority.13 There is research examining the climate of safety in health care as it impacts worker injuries … reactions of supervisors, the training in use of technology, performance appraisals that include safety, pressures … perceptions of work group members regarding the protection of patients from medication errors and injuries … teamwork, risk perception, process auditing, A Hospital Safety Climate Measure 441 production pressures

444. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
     April 01, 2018 - This measure calculates the rate of adverse events (patient harm)—defined as unintended physical injury … Black and Hispanic newborns are at higher risk of birth trauma (Miller, et al., 2003). … Although AEs most often result in transient harms, some lead to permanent injury and death. … : "Naloxone administration," “Health care- associated infections: positive C. difficile test,” and "Pressure … Internal pressures, such as a punitive culture that leads to underreporting of medical errors, may influence

445. Timely Antibiotics for Children With Severe Sepsis or Septic Shock (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-fullreport.pdf
     April 02, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for therapy of the underlying injury once shock is present. … 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

446. Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
     May 01, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (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. … 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

447. Implement Teamwork and Communication for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
     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, … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60

448. Final Progress Report: Making Acute Care More Patient Centered, Patient Safety Learning Laboratory (PSLL) (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/bates3-report.pdf
     January 01, 2024 - concordance by patients and care team members, and the incidence of patient falls and fall-related injuries … The effect of the intervention on patient falls (dichotomized as fall/no fall) and falls with injury … (dichotomized as falls with injury/no injury) was analyzed using logistic regression estimated via … Scope Inpatient adverse events (AEs) are patient injuries due to medical management that prolong hospitalization … Bowel Regimen, Venous Thromboembolism (VTE) Prophylaxis, Opioid Management, Antibiotic Management, Pressure

449. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lannon2-report.pdf
     January 01, 2024 - Predict and prevent nephrotoxic medication-associated acute kidney injury in noncritically ill hospitalized … Electronic Health Record Identification of Nephrotoxin Exposure and Associated Acute Kidney Injury. … -55 27803957 2017 NPC-QIC Improvement/outcomes Frank G, Walsh KE, Wooton S, et al Impact of a Pressure … Injury Prevention Bundle in the Solutions for Patient Safety Network Pediatric quality & safety

450. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
     September 01, 2017 - Report data help identify residents with new ADL decline, fall risk, or fall injury, therefore at risk … and Rehab  Managers Weekly huddle to review residents at risk for ADL decline or fall or with fall injury … with stage 2 or above pressure ulcers at risk for infection who potentially require hospitalization/ … Reports provide information about current and changing risks for pressure ulcer healing and can aid root … Discharge diagnoses were dehydration, fall with injury, cellulitis, and angina.

451. A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Reige.pdf
     March 01, 2004 - an acute skeletal muscle relaxant medication for nearly a year; it was originally prescribed for injuries … Elderly people are at a higher risk for falls resulting in serious injury, and when a person is dizzy … When an elderly patient falls, serious injury may occur. … Part of the medication renewal process involves checking the patient’s blood pressure or performing

452. NAA National Webinar July 2024 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/slides-healthcare-safer-by-design.pdf
     August 20, 2024 - Use of an ADC’s override feature should be routinely tracked and monitored. 2023 #6 Inflatable Pressure … ©2024 ECRI | ECRI Confidential47 Surgical Fire Response • Immediate action • Mitigate risk of injury

453. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
     January 01, 2024 - The report estimated more than a million injuries and nearly 100,000 deaths attributable to medical … medication opportunities (not on an indicated med); (4) failed intermediate outcomes – e.g., high blood pressures … with CHF who are euvolemic (compensated) and on a low dose of an ACE inhibitor with systolic blood pressure … of 110, diastolic blood pressure of 80, and a heart rate of 76, adding a beta blocker is the next most

454. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
     May 01, 2017 - fetal criteria for procedures that increase risk for cord prolapse47 such as— amniotomy intrauterine pressure … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

455. Presentation: Optimize Your Briefings and Debriefings
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
     December 01, 2017 - defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury … Serious injury specifically includes loss of limb or function. … Confirm patient identity, site, and procedure Review perfusion plan, including– Cannulation Perfusion pressure … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion … for improvement Ask if instrument, sponge, and needle counts are correct Record name of procedure and wound

456. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
     January 01, 2004 - Several case reports suggest that these extrinsic risks do, in fact, exert significant pressures on … near miss” represents the identification of a potential safety problem, prior to it resulting in an injury … Typically the same system failures that might have resulted in an injury also are present in a near … patient safety can be improved by identifying latent failure prior to the occurrence of a catastrophic injury … Because an injury has not occurred, liability is limited.

457. 3. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
     January 01, 2024 - that patients with diagnosis-related claims were  2.33 times more likely to die than to have a minor injury … have been associated with increased medical errors and stress, anxiety, and burnout. 113,114 Time pressure … of diagnostic safety found the need to prioritize research on system factors, such as workload, time pressure … considering alternative diagnoses, taking a diagnostic timeout to pause and reflect, and minimizing time pressures … themes of the diagnostic process, including diagnosis as a social phenomenon and distractions and time pressures

458. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
     January 01, 2010 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

459. Advancing Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advancing/index.html
     July 01, 2022 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

460. Development of a Screening Tool for Safe Wheelchair Seating (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Gavin.pdf
     January 01, 2001 - systems do not fit the individual needs of nursing homes residents, many problems can become evident: pressure … diagnosis, cognitive status, communication ability, sensation level, skin integrity (presence/absence of pressure … reductions (e.g., staff time saved if residents could self-propel, elimination of repositioning needs, injury … Nursing home wheelchair users: seat comfort and peak pressures [unpublished doctoral thesis].