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721. Final Progress Report: Risk Analysis of Pediatric Chemotherapy Processes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14295%20Shenep-draft-1.pdf
     June 01, 2005 - 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

722. 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

723. 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 .

724. 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

725. 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.

726. National Healthcare Quality and Disparities Report Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2016-ptschartbook.pdf
     July 19, 2017 - 60 80 100 120 140 160 2010 2011 2012 2013 2014 2015 R at e 1 ,0 0 0 D is ch a rg e s Pressure … 60 80 100 120 140 160 2010 2011 2012 2013 2014 2015 R at e 1 ,0 0 0 D is ch ar ge s Pressure … ■ An ADE is an injury—including physical harm, mental harm, or loss of function— resulting from medical …  Importance: Normal wound healing after an operation is an important marker of good care. … The home health team should regularly change wound dressing and teach the patient about wound care

727. 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

728. 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

729. 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.

730. 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

731. 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

732. 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.

733. Module 2: How To Manage Change—Training Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-2/guide.html
     September 01, 2017 - applied to other quality improvement efforts in a hospital, such as preventing: Hospital-acquired pressure … injuries.

734. Module 2: How To Manage Change (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_fall-prevention.docx
     August 24, 2017 - applied to other quality improvement efforts in a hospital, such as preventing: Hospital-acquired pressure … injuries.

735. 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
     September 30, 2024 - ■ 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

736. 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

737. 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

738. Icu-Clinical-Decision-Making-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/icu-clinical-decision-making-transcript.docx
     January 01, 2015 - Are you a medical, a surgical, a cardiothoracic, coronary, other such as the neuro critical care, trauma … an indwelling urinary catheter related to the use of paralytics, sedative, hypnotics or orthopedic trauma … 10:00 o’clock your patient is unsedated on [inaudible 00:29:16] fall they have a catheter but their injury … I’m specifically asking about the evidence for that and the potential complications, pressure alters … We have worked with our pressure alter team to look at skin breakdown prevention.

739. ICU Clinical Decision-Making; Processes to Improve Catheter Insertion and Removal Choices; Science of Safety Concepts to Improve ICU Culture | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/icu-clinical-decision-making-transcript.html
     December 01, 2017 - Are you a medical, a surgical, a cardiothoracic, coronary, other such as the neuro critical care, trauma … an indwelling urinary catheter related to the use of paralytics, sedative, hypnotics or orthopedic trauma … 10:00 o'clock your patient is unsedated on [inaudible 00:29:16] fall they have a catheter but their injury … I'm specifically asking about the evidence for that and the potential complications, pressure alters … We have worked with our pressure alter team to look at skin breakdown prevention.

740. Slide 1
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/effectivetreatment/qdr2015-chartbook-effective.pptx
     September 06, 2016 - United States. 12 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. 118 Importance of Treatment In 2011