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701. Learning from Errors in Ambulatory Pediatrics (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
     February 01, 2004 - Because of the age of pediatric patients, when an error leads to injury it may have an impact on the … No complete loss of consciousness -- mom caught him with no head injury sustained. … post-term newborn infant with mild respiratory distress syndrome requiring continuous positive airway pressure … The occurrence of an error did not imply harm or injury to the patient.

702. Case 2. Central Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case2.html
     November 01, 2014 - Participation is required in the following priority areas: falls and fall injuries, pressure ulcers, … For example, in 2008 the national system launched a campaign to have zero preventable injuries or deaths … , the department was working toward certification as an American College of Surgeons (ACS) Level II Trauma … The ED successfully launched a trauma center and identified a new director in early 2010. … Staff perceived a shift of work to other staff because of the pressures of Lean process.

703. Imp-Handouts (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/imp-handouts.pdf
     June 28, 2017 - Report data help identify residents with new ADL decline, fall risk, or fall injury, therefore at risk … Rehab Managers Weekly huddle to review residents at risk for ADL decline or fall or with fall injury … 2 or above pressure ulcers at risk for infection who potentially require hospitalization/ED visit … Reports provide information about current and changing risks for pressure ulcer healing and can aid … Discharge diagnoses were dehydration, fall with injury, cellulitis, and angina.

704. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=165
     January 01, 2024 - Keywords: Blood Pressure, Heart Disease and Health, Cardiovascular Conditions, Racial and Ethnic Minorities … This study used data on mass shootings to examine the proximity of adult trauma centers, pediatric trauma … centers (TCs), and non–trauma center hospitals to such events. … Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. … systems or e-cigarettes) among children and adolescents may help decrease tobacco-related illness and injury

705. Research on the Integration of Behavioral Health in Primary Care webinar
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/behavioral-health-primary-care-webinar.pptx
     March 07, 2024 - I would’ve never thought to refer him to it because of the level of his brain injury” Tack, E., Lakhtakia … There are key SSDOH in driving blood pressure disparities for example, like lack of access to healthy

706. Chartbook on Hispanic Health Care: Slide Presentation—Part 3 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt3.html
     May 01, 2018 - Slide 10 Adults who needed care right away for an illness, injury, or condition in the last 12 months … ) among Hispanics, 2002-2012 Image: Graphs show adults who needed care right away for an illness, injury … Slide 11 Children who needed care right away for an illness, injury, or condition in the last 12 … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … Importance: Many patients who receive home health care are recovering from an injury or illness and

707. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-051413.ppt
     January 01, 2013 - Reduce antibiotic use Reduce potential of increased resistance and Clostridium difficile disease Reduce trauma … (mechanical complications): Metal and urethral injury Hematuria Hospitalists Geriatricians Infectious … Inappropriate urinary catheter use may negatively affect the surgeon’s profile Risk of infection and trauma … They may lead to urinary tract infections and cause mechanical trauma to the urethra and bladder. … They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient

708. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=70
     January 01, 2024 - Keywords: Blood Pressure, Prevention, Evidence-Based Practice, Cardiovascular Conditions Barreto … describe the development and feasibility of a multidisciplinary approach to caring for acute kidney injury … This study investigated whether pre-dialysis systolic blood pressure (preSBP) and interdialytic weight

709. 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

710. 2018 National Healthcare Quality and Disparities Report Executive Summary
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2018qdr-patsaf-chartbook.pptx
     October 01, 2019 - events include postoperative infection (acute or early deep), dehiscence, necrosis, hematoma, nerve injury … events include postoperative infection (acute or early deep), dehiscence, necrosis, hematoma, nerve injury … from the date of the index admission; or mechanical complications, periprosthetic joint infection, or wound … from the date of the index admission; or mechanical complications, periprosthetic joint infection, or wound … treatment with mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries

711. Webinar Transcript - The National Quality Strategy and the Public Sector: Federal Agency Alignment to the Six Priorities | Agency for Healthcare Research and Quality
     www.ahrq.gov/workingforquality/events/webinar-federal-agency-alignment-to-the-six-priorities.html
     November 01, 2016 - We work to prevent the leading cause of illness, injury, disability, and death. … We've displayed performance on the ABCs, which are appropriate aspirin use, blood pressure control, control … tobacco and got preventive care, we still have to address modifiable risk factors, including blood pressure … their profit according to the extent to which they're able to assist their members in controlling blood pressure

712. 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

713. 2022 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-appendix-combined.pdf
     October 25, 2022 - HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … pressure ulcer MDS 2019 Low-risk, long-stay nursing home residents with a catheter inserted and left … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018 … HCUP 2019 Home health care patients whose management of oral medications improved OASIS 2020 Birth trauma … MDS 2019 Short-stay nursing home patients with pressure ulcers that are new or worsened MDS 2018

714. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE.pdf
     January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home

715. 2023 National Healthcare Quality and Disparities Report Appendixes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
     January 01, 2023 - 1,000 elective-surgery admissions, age 18 and over HCUP 2020 Reclosure of postoperative abdominal wound … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home … 2020 Home health care patients whose management of oral medications improved OASIS 2021 Birth trauma … stages 2-4 pressure ulcer or unstageable pressure ulcer MDS 2021 Low-risk, long-stay nursing home

716. Health Literacy: Making It Easier for Patients to Find, Understand, and Use Health Information and Services (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/health-literacy/3rd-edition-toolkit/health-literacy-education-presentation-tool-3a.pdf
     January 01, 2019 - Afra wound up with chlamydia, which damaged her fallopian tubes and resulted in her not being able to … • Ed wound up in the hospital from taking both medicines. 16 Presenter Notes Presentation Notes … Ed wound up in the hospital from taking both medicines. … Technical Terms Say Not Pain killer Analgesic Swelling Inflammation Feverish Febrile High blood pressure … Hypertension Wound Lesion Injury Insult Presenter Notes Presentation Notes We’ve been trained in

717. Chartbook on Women's Health Care: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/womenhealth/womenh-slides.html
     March 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 . Accessed September 1, 2015.

718. 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

719. 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

720. 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