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521. 2014-Women-Chartbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/2014-women-chartbook.pdf
     January 01, 2014 - For example, only half of people with high blood pressure have it controlled. … High blood pressure costs the Nation $46 billion each year. … mostly attributable to sudden unexpected infant death (SUID), congenital anomalies, infection, and injury … Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2013). http://www.cdc.gov … /injury/wisqars/index.html .

522. Creating a Culture of Patient Safety through Innovative Hospital Design (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Reiling.pdf
     January 01, 2004 - Unfortunately, a small portion of errors do result in an “adverse event”—an injury caused by medical … For example, a 1991 Harvard Medical Practice Study reported that 69 percent of injuries suffered by … hospitalized patients in New York State in 1984 were the result of errors, and nearly 14 percent of these injuries … It may elevate blood pressure, increase pain, alter quality of sleep, and reduce overall perceived

523. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/shenep-report.pdf
     January 01, 2024 - Review effectiveness of 60%. 6 Significant effect/ Minor injury Actual error occurred and reached … Page 8 8 Extreme effect/major injury Actual error occurred and reached the patient. … Error would result in a major injury for the individual served, including permanent patient harm … detect Remote likelihood that current controls will detect. 10 Catastrophic effect; terminal injury … Discussion Although CPOE is supported philosophically by multiple groups that exert significant pressure

524. Final Progress Report: Quality Factors in Nursing Home Choice (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/congdon-magilvy-report.pdf
     January 01, 2024 - homes include indicators of physical care, such as rate of restraint use (physical and chemical), pressure … sore prevalence, urinary tract infections, pain, injuries, hospitalizations, functional decline; staffing … follows: .626 for urinary tract infections, .528 for weight loss, .853 for tube feeding, .570 for pressure … indicated that NHs with higher total hours of care had higher rates of urinary tract infections and pressure

525. Ratio of Magnetic Resonance Imaging Scans to Computed Tomography Scans for the Evaluation of Children with Atraumatic Seizure: Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-fullreport.pdf
     November 01, 2019 - These complications include compromised airway, hypoxia leading to central nervous system injury, and … moderate and deep sedation carry risk of airway compromise, hypoxia resulting in central nervous system injury … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … ; regurgitation of stomach contents with subsequent aspiration (inhalation) pneumonia; injury to arteries … , veins, or nerves; alterations in blood pressure; and/or irregular heart rhythms (Society for Pediatric

526. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
     January 01, 2014 - The term safety refers to reducing risk from harm and injury, whereas the term quality suggests striving … Information Form, and Summary of Initial Report Form) and then applying Common Formats for falls, pressure

527. Prescribers-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/prescribers-facilitator-guide.docx
     June 01, 2021 - unanticipated event in a health care setting resulting in death or serious physical or psychological injury … Half of the respondents in that study reported feeling pressure to give a medication for which they questioned

528. Meeting Minutes, November 2017 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
     February 01, 2018 - Preliminary data on the use of the training materials showed significant decreases in falls with injury … AHRQ also released training materials for preventing pressure ulcers in hospitals. … Preliminary data on use of the materials showed significant decreases in pressure ulcers during a 1-year

529. Chartbook on Effective Treatment: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/effectivetreatment-slides.html
     April 01, 2018 - Most Costly Conditions, 2013 Condition Total Expenses (Millions) Report Section Trauma-related … Blood pressure under control is defined as having a mean systolic blood pressure <140 and mean diastolic … blood pressure <90 among all hypertensive patients. … , blood pressure control among people with diagnosed high blood pressure remains a problem. … Increased risk of death from car crashes and other injuries.

530. Final Progress Report: Process Reliability and Organizational Learning in Home Health Care (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
     January 01, 2025 - Two hospitalizations (1.5%) were the result of injuries that were unrelated to home care. … 120 Decline resulting from patient's condition Complication of earlier care New diagnosis Injury … benefit will be provided in those visits (e.g., an agency cannot simply increase the frequency of wound … Identifying barriers to reporting changes in condition: unclear expectations, time/production pressure

531. Methods (continued, 2) | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3a.html
     July 01, 2018 - External motivation may also come from pressures or "pushes" from external organizations. … hospital-associated infections, reducing risk of harm from patient falls, and preventing hospital-associated pressure … unanticipated event in a health care setting resulting in death or serious physical or psychological injury … level (e.g., on PFACs and decisionmaking committees). 103,104 Sentinel events also lead to external pressures

532. Slide 1
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/womenhealth/2014nhqdr-womenhealth.pptx
     January 01, 2020 - Importance: About 70 million American adults (29%) have high blood pressure (Nwankwo, et al., 2013). … High blood pressure costs the Nation $46 billion each year. … mostly attributable to sudden unexpected infant death (SUID), congenital anomalies, infection, and injury … Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2013). http://www.cdc.gov … /injury/wisqars/index.html .

533. Final Progress Report: Short-term Clinical Deterioration After Acute Pulmonary Embolism (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/weekes-report.pdf
     January 01, 2025 - important indicator of acute PE of moderate to high severity is an acute increase in right ventricular pressure … abnormality is commonly assessed in two ways: 1) laboratory surrogates of myocardial stretch and injury … and 2) imaging assessments for RV dilatation, pressure increases, and decreased systolic function. … point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure

534. Pediatric Diagnostic Safety: State of the Science and Future Directions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-pediatric-safety.pdf
     September 01, 2023 - status, extremes of age, delirium, or poor information exchange between health systems; ■ Time pressures … Identification of children at very low risk of clinically- important brain injuries after head trauma … Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project … 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.

535. Facilitator Guide: Optimize Your Briefings and Debriefings (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings_facnotes.docx
     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. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion

536. Optimize Briefings and Debriefings: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/opt-briefings-fac-notes.html
     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. … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion

537. Cesarean Delivery for Nulliparous (NTSV) Women (Appropriate Use) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/perinatal/chipra-0082-fullreport.pdf
     March 01, 2016 - delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … nonmedical factors such as provider density, the capacity of the local health care system, and malpractice pressure … o Have a physical abnormality or injury to their brain or spinal cord. … For example, there may be fewer surgical injuries and fewer infections. … vaginally is more likely to have a nerve injury that affects the shoulder, arm, or hand.

538. Improving Healthcare Safety by Enhancing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-medication-safety.pdf
     April 30, 2025 - ■ To reduce medication-associated acute kidney injury in nine pediatric hospitals, one project disseminated … Neither intervention affected blood pressure control. … Participating in a learning network that required all participants to implement Nephrotoxic Injury Negated … enforcement actions (e.g., increased borrowing behavior to avoid citations for “drug not available,” time pressures … analgesics was most common among children with outpatient procedures, dental procedures, traumatic injuries

539. The San Diego Center for Patient Safety: Creating a Research, Education, and Community Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Pratt.pdf
     March 01, 2004 - The usual time Advances in Patient Safety: Vol. 4 36 pressures and competing demands kept early … identification and wrong-site surgery; (3) event reporting, including near misses; and (4) physical injury … As the collaborative and Consortium have grown, there has been increasing pressure to take on new initiatives

540. Meeting Minutes, March 2021 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2021-03-nac/nacmtg031821-minutes.html
     July 01, 2021 - revealed improvement in patient safety overall, especially with regard to urinary tract infections and pressure … A health disparity means a higher burden of illness, injury, disability, or mortality experienced by