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761. Executive Summary | Agency for Healthcare Research and Quality
     www.ahrq.gov/health-literacy/professional-training/lepguide/exec-summary.html
     September 01, 2020 - not be harmed by the care that is intended to help them, and they should remain free from accidental injury … admissions and/or discharge. 68 Greater risk of line infections, surgical infections, falls, and pressure

762. Measure 1, Section 14, Attachment 1 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-88-measure-1-section-14-attachment-1.pdf
     January 01, 2011 - culminate in significant costs attributable to greater health-care needs, more frequent unintentional injury … culminate in significant costs attributable to greater health-care needs, more frequent unintentional injury … (with or without behavior therapy): At least 2 follow-up visits with: Height, weight, and blood pressure

763. ADHD Performance Measurement Set (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-14-attach-1.pdf
     January 01, 2011 - culminate in significant costs attributable to greater health-care needs, more frequent unintentional injury … culminate in significant costs attributable to greater health-care needs, more frequent unintentional injury … with or without behavior therapy): At least 2 follow-up visits with: Height, weight, and blood pressure

764. Final Progress Report: Improving the Safety of Primary Care by Measuring Adverse Events and Improvement (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/kennerly-report.pdf
     January 01, 2024 - implement interventions to address these.1 Development of the BI-OTT Consistent with the “no preventable injuries … in terms of reported medical expenditures, employment status, or work days missed due to illness or injury … High blood pressure (hypertension)? 11(64.7) 23(67.6) 0.83** d. High cholesterol (hyperlipidemia)? … 18.8) During 2010 about how many days did you miss work at a job or business because of illness or injury … patients in terms of reported medical expenditures, employment status, or days missed due to illness or injury

765. Catheter Ablation for Atrial Fibrillation: Topic Refinement - Project ID: CRDT0913 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/afib_topicref.pdf
     January 01, 2020 - peripheral vascular complication [including pseudoaneurysm, hematoma at catheter insertion site, vascular injury

766. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-care-coordination.pdf
     June 01, 2024 - Illinois R36 HS23072 [Grant] Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Report Purpose: To examine the influence of nurse continuity on the prevention of hospital- acquired pressure … the dynamic changes in risk and understand the frequency that human attributes and organizational pressures … As hospitals face increasing financial constraints, the pressure to favor productivity and throughput … examine transition of care factors that contribute to risk and hazards associated with iatrogenic injury

767. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
     September 01, 2012 - Adverse event*: Any injury caused by medical care. … include pneumothorax from central venous catheter placement, anaphylaxis to penicillin, postoperative wound … Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Teamwork training improves the clinical care of trauma patients. … About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before.

768. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf
     September 01, 2012 - Adverse event*: Any injury caused by medical care. … include pneumothorax from central venous catheter placement, anaphylaxis to penicillin, postoperative wound … Similarly, postoperative wound infections count as adverse events even if the operation proceeded with … Teamwork training improves the clinical care of trauma patients. … About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before.

769. Organizational Climate of Staff Working Conditions and Safety—An Integrative Mode (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Stone.pdf
     January 01, 2004 - as likely as nurses on well-staffed and better-organized units to report risk factors, needlestick injuries … Implementing evidence-based medicine: the role of market pressures, compensation incentives, and culture … Effects of hospital staffing and organizational climate on needlestick injuries to nurses.

770. Improving the Value of Patient Safety Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
     June 12, 2008 - identified insufficient staff knowledge as the main cause of events related to the use of intracranial pressure … Severity scoring (i.e., severity of patient injury and frequency of occurrence) is one approach to prioritizing

771. High-Hanging Fruit: Improving Transitions in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
     March 27, 2008 - Signovers provide more than information (e.g., name, blood pressure, diagnosis); they also support macrocognitive … Patterns of communication breakdowns resulting in injury to surgical patients.

772. Prescribing Safety in Ambulatory Care: Physician Perspectives (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rundall.pdf
     January 01, 2003 - Human: Building a Safer Health System, identified medical errors as a leading cause of death and injury … control … and we’re treating 85-year-olds with drugs that will knock them out just to lower their blood pressure

773. 2021 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2021qdr-datasources.pdf
     December 31, 2021 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … include mode of arrival, waiting time, duration of time in the ED, initial vital signs, and cause of injury … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries

774. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/handout.html
     November 01, 2017 - The On-Time reports may also take some of the pressure off communication practices by automatically providing … She did make a recommendation for a medication change and some increased monitoring of blood pressure

775. Fallspximpl-Handouts (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.docx
     November 15, 2017 - The On-Time reports may also take some of the pressure off communication practices by automatically providing … She did make a recommendation for a medication change and some increased monitoring of blood pressure

776. 2019 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
     December 01, 2020 - state-specific data on preventive health practices and risk behaviors linked to chronic diseases, injuries … The examination includes physical measurements, such as blood pressure and dental examinations, and … from each family in the house and collects data on topics including health status and limitations, injuries … infections; seven types of adverse events associated with surgery; patient falls; and hospital-acquired pressure … events associated with the hospital stay and not present on hospital admission (inpatient falls and pressure

777. Barriers Associated with Medication Information Handoffs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Bayley.pdf
     January 01, 2004 - actually access information from other settings varies with patient complexity, patient acuity, and time pressures … This reflects their focus on immediate treatment and stabilization of an acute illness or injury. … definitions are not personal failures as much as imperatives caused by the organizational structure and the pressures

778. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
     July 18, 2008 - The failures15 may be related to faulty processes, information technology support, time pressures, inadequately … setting, which represented 2.5 percent of ED visits, 6.7 percent of hospitalizations for unintentional injuries … antibiotics, immediate x-ray, repeat neuro-circ checks, and immediate orthopedic consultation for wound … We’ll monitor for any other injuries.

779. Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-safety-transitions-care.pdf
     June 01, 2023 - transition is prone to technical and diagnostic error due to not only the high patient acuity and time pressure … exposure to unnecessary interventions, and preventable harm.62 During the OR-to-ICU handoff, time pressure … Critical care settings are underrepresented in implementation science literature,84 due in part to time pressure … inherent in caring for critically ill patients.75 Yet it is that time pressure that makes a sustainable … Patterns of communication breakdowns resulting in injury to surgical patients.

780. Ambulatory Safety and Quality Program: Health IT Portfolio (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ambulatory-safety.pdf
     July 01, 2010 - protocol using an EHR to identify patients in need of treatment intensification for systolic blood pressure … treatment device and an internet-based portal that tracks management of continuous positive airway pressure … Focus Area(s): Drug-induced injury in the ambulatory geriatric population Type of Health IT: EMR Principal