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781. Making Information Technology a Team Player in Safety: The Case of Infusion Devices (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Nemeth.pdf
     January 01, 2002 - particular kinds of medications to desired effect such as vasopressors, which are used to control blood pressure … Adverse events including device- related deaths and serious injuries must be reported to the FDA and

782. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/21093-Lambert-draft-1.pdf
     November 20, 2017 - Antidepressant treatment and suicide attempts and self-inflicted injury in children and adolescents. … Antidepressant treatment and suicide attempts and self-inflicted injury in children and adolescents … also investigate our strategy’s impact on intermediary clinical outcomes, including systolic blood pressure … measures included medication understanding, adherence, and clinical measures (hemoglobin A1c, blood pressure

783. Final Progress Report: TOP-MEDS CERT: Tools for Optimizing Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/lambert-report.pdf
     January 01, 2024 - Antidepressant treatment and suicide attempts and self-inflicted injury in children and adolescents. … Antidepressant treatment and suicide attempts and self-inflicted injury in children and adolescents … also investigate our strategy’s impact on intermediary clinical outcomes, including systolic blood pressure … measures included medication understanding, adherence, and clinical measures (hemoglobin A1c, blood pressure

784. National Healthcare Quality And Disparities Report Patient Safety Chartbook (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/2017qdr-patsafchartbook.pdf
     October 01, 2018 - per 1,000 instrument-assisted deliveries • Birth trauma - injury to neonate per 1,000 selected live … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … 40 60 80 100 2014 2015 2016 2017 2018 2019 GOAL Ra te p er 1 ,0 00 D is ch ar ge s Pressure … Adverse Drug Events • An adverse drug event (ADE) is an injury—including physical harm, mental harm, … The home health team should regularly change wound dressing and teach the patient about wound care.

785. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.pdf
     November 15, 2017 - The On-Time reports may also take some of the pressure off communication practices by automatically … She did make a recommendation for a medication change and some increased monitoring of blood pressure

786. PowerPoint Presentation: Learn From Defects for Sustainability
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
     December 01, 2017 - If someone is in danger of injury or an emergent procedure is missing a vital resource, we do what needs … Were decisions made under pressure, despite distractions, or without appropriate knowledge of case or

787. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/crane.html
     August 01, 2017 - percent Information exchange with other settings 49 percent 53 percent 54 percent Work pressure … Patients’ and doctors’ attitudes to amount of information given after unintended injury during treatment

788. Universal ICU Decolonization: An Enhanced Protocol (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/universalicu.pdf
     September 01, 2013 - Wound Care 1. For what types of wounds is chlorhexidine (CHG) application safe? … to avoid causing additional soft tissue damage or extension of the wound due to pressure against the … #2: Nasal Trauma  Do NOT use mupirocin if nostril(s) are packed. …  CHG will not harm occlusive dressing (e.g., wound vacs).  Do NOT use on large or deep wounds … CHG can cause permanent injury if it comes in direct contact with nerves and is allowed to remain there

789. Simulation-Based Education Improves Patient Safety in Ambulatory 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-Lavelle_33.pdf
     March 12, 2008 - related to pediatrics, respiratory emergencies, and seizures, the urgent care staff also requested trauma … scenarios (e.g., lacerations, fractures, head injuries, spinal cord injuries). … to obtain a more easily transportable, moderate-fidelity manikin with heart/lung sounds and blood pressure

790. AHRQ Safety Program for Perinatal Care Summary Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/sppc-summary_report.pdf
     May 01, 2017 - Rate-Injury to Neonate o Obstetric Trauma Rate-Vaginal Delivery With Instrument o Obstetric Trauma … Rate-Injury to Neonate (AHRQ Patient Safety Indicator 17) • Obstetric Trauma Rate-Vaginal Delivery … With Instrument (AHRQ Patient Safety Indicator 18) • Obstetric Trauma Rate-Vaginal Delivery Without … , they sustained the use of TeamSTEPPS tools and techniques through peer support and positive peer pressure … • More favorable changes in the obstetric trauma with instruments measure (PSI 18) for units with

791. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.docx
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

792. Return on Investment Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.docx
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

793. INSTRUCTIONS: Return on Investment Estimation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/f1-returnoninvestment.pdf
     January 01, 2009 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

794. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=41
     January 01, 2024 - in radiation oncology such as better communication and documentation, and reduced time and workload pressures … odds of any complication including cardiac complications, lower extremity ischemia and acute kidney injury

795. 043-Vap-Prevention-Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/043-vap-prevention-notes.docx
     October 01, 2024 - Cancer and trauma patients are also at a higher risk of developing VAP than other populations. … These include high-flow oxygen or noninvasive positive pressure ventilation (NIPPV). … Patients who have suffered a stroke or other neurologic injury are those that come to mind most often

796. 2016 CMS Quality Strategy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/workingforquality/2016-cms-agency-specific-plan.pdf
     January 01, 2016 - occur each year, leading to 99,000 deaths, while adverse medication events cause more than 770,000 injuries … CMS aims to partner with health care providers in a continual effort to reduce the risk for injury from … The key interventions are referred to as the “ABCs”: appropriate aspirin therapy, blood pressure control … Surviving Sepsis Campaign, Healthy People 2020, as well as screening and treatment for high blood pressure

797. 43-Pathway-Worksheet (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/43-pathway-worksheet.docx
     June 01, 2023 - record systems have clinical decision support that can be helpful in flagging triggers (e.g., low blood pressure … Tidal volumes of 6–8 mL/kg of predicted body weight with positive end expiratory pressures of 5 cm H2O … approach: Intraoperative tidal volume 6–8 mL/kg of predicted body weight with positive end expiratory pressures … All ISCR Pathways Wound Protector Use Recommended approach: Wound protectors are recommended for all … is drinking liquids unless the patient has difficulty with oral intake, there is evidence of kidney injury

798. Return on Investment Estimation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/f1_pdi_returnoninvestment.pdf
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

799. Return on Investment Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/f1_combo_returnoninvestment.pdf
     January 01, 2013 - For example, improvement actions might reduce hospital-associated infections, rates of pressure ulcers … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

800. Final Progress Report: Midcoast Maine Patient Safety and IT Integration (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/buckley-report.pdf
     January 01, 2024 - movement is multifaceted and complex, embracing a range of perspectives on the etiology of patient injuries … Such pressures may be the stimulus for beneficial innovation, as necessity spawns invention, and traditional