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801. Final Progress Report: What About Mom? Using Administrative Data To Develop Measures for Monitoring Healthcare Quality in Pregnancy & Childbirth (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/gregory-report.pdf
     January 01, 2024 - cesarean rates may be examined for an association with postpartum 8 hemorrhage or unintentional injuries … /consultants to quality improvement personnel, shows that many institutions do respond to external pressures … to be specific for pregnancy Yes 0.1487 + 0.1980, 0.7886 (0- 1.1534) PSI #14: Post-operative wound … Alternative codes evaluated Yes 1.0931 + 1.4021 0.6600 (0-13.6126) excluding clavicle, brachial nerve injury … Maternal birth trauma Use AHRQ definition PSI 18 and 19?

802. Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/liability/crane.html
     August 01, 2017 - 59 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

803. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
     January 01, 2024 - Significance Preventable Adverse Drug Events in Community Pharmacies Adverse drug events (ADEs), defined as injuries … PADEs lead to about 4% (range, 1.4-15.4%) of hospital admissions8,9,10,11,12,13 and account for injuries … medications are an essential component of drug therapy, they carry a significant risk of causing serious injuries … high-volume pharmacies to low- volume pharmacies are examples of interventions to help reduce time pressures … Assessing patient safety risk before the injury occurs: an introduction to socio-technical probabilistic

804. Final Progress Report: Emergency Department Overcrowding and Quality of Acute Asthma Care for Children (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/sills-report.pdf
     January 01, 2024 - Exclusion criteria for the fracture population included any ICD-9 code indicating major trauma, a second … with ILI to the EDs), with far lower than expected rates of ICU and non-ICU admission and positive pressure … Emergency department analgesic use in pediatric trauma victims with fractures. … Underuse of analgesia in very young pediatric patients with isolated painful injuries. … Physician pain reminder as an intervention to enhance analgesia for extremity and clavicle injuries in

805. Chapter 4. Results | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/shuttered/acfselection/chapter4.html
     July 01, 2018 - Ambulatory acute care - i.e., triage and minor wound care. Chronic care. … The scope of care includes: nursing care for stabilized internal medicine, trauma, orthopedic, and … efforts to educate governments, businesses, and the public on measures they can take to reduce loss and injury … Flannel   Blanket, infant white, cotton Blanket, thermal WHI2.2 lb 48 Blood Pressure … Unit Aneroid, Adult, L/F Blood Pressure Unit Aneroid, Child, L/F Brief, Adult Trimline

806. State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dx-safety-older-adults.pdf
     January 17, 2024 - to his physical therapist 23 days after falling off a ladder, resulting in a mild traumatic brain injury … Lamjoun, et al. (2023)39 Normal pressure hydrocephalus and mania symptoms: case report A 54-year-old … e.g., registered nurses, clinical pharmacists, social workers, nutritionists) and face institutional pressure … Normal pressure hydrocephalus and mania symptoms: case report. … against overtesting, overdiagnosis, and overtreatment of older adults: thinking beyond imaging and injuries

807. 2022 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-datasources.pdf
     December 01, 2022 - 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 … patient’s age, gender, race, and ethnicity; patient’s expressed reason for visit; intentionality of injury … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

808. 2023 National Healthcare Quality and Disparities Report Data Sources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
     December 01, 2023 - state-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries … from each family in the house and collects data on topics including health status and limitations, 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 … ulcer adverse events Pressure Ulcer Venous thromboembolism/pulmonary embolism (VTE/PE) not related

809. Hemoglobin S Monitoring Prior to Chronic Transfusion Among Children With Sickle Cell Anemia (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-214-fullreport.pdf
     February 01, 2019 - percent experience a stroke by 20 years of age, and another 13 percent show evidence of silent infarcts (injuries … Neurologic injury causes serious morbidity in over 25 percent of patients with sickle cell anemia and … Risk factors for stroke include a history of transient ischemia attack, elevated systolic blood pressure

810. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults-references.html
     September 01, 2024 - Normal pressure hydrocephalus and mania symptoms: case report. … against overtesting, overdiagnosis, and overtreatment of older adults: thinking beyond imaging and injuries

811. Ten Considerations for Easing the Transition to a Web-based Patient Safety Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ulep.pdf
     January 01, 2004 - dealing with falls, medication safety, lab specimen safety, identification problems, and employee health injuries … Ever-increasing budget pressures often lead to staffing cuts, causing overburdened employees to develop

812. AHRQ Grant Final Progress Report: Real-Time, Wireless, Networked Feedback for Bed-Tilt Compliance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/thomas-report.pdf
     June 30, 2015 - ventilator-associated pneumonia, trading off from setting the angle to something less than 30 degrees, which prevents pressure … National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: Does it … J Trauma Acute Care Surg 2013;74(2):354-362. 18. Lawrence P, Fulbrook P. … J Trauma Injury Infect Crit Care 2008;64(1):22-29. 20. Bingham M, Ashley J, De Jong M, et al. … Trauma VAP SWAT team: A rapid response to infection prevention.

813. AHRQ Grant Final Progress Report: Real-Time, Wireless, Networked Feedback for Bed-Tilt Compliance (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/thomas1-report.pdf
     January 01, 2024 - ventilator-associated pneumonia, trading off from setting the angle to something less than 30 degrees, which prevents pressure … National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: Does it … J Trauma Acute Care Surg 2013;74(2):354-362. 18. Lawrence P, Fulbrook P. … J Trauma Injury Infect Crit Care 2008;64(1):22-29. 20. Bingham M, Ashley J, De Jong M, et al. … Trauma VAP SWAT team: A rapid response to infection prevention.

814. Improving Patient Safety in Medical Offices: A Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/2010/moimpptsaf.pdf
     January 01, 2010 - Work Pressure and Pace .............................................................................. … those receiving usual care, including being more likely to meet goals related to blood glucose, blood pressure … toward understanding and accepting the idea of a blameless culture within the context of medical injury … Work Pressure and Pace 1.

815. Learning From Defects Through Sensemaking: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-fac-notes.html
     December 01, 2017 - reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … It’s tough when the pressure is high and the patient is at risk.

816. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
     December 01, 2017 - reengineer the system to catch holes before they line up, and end system gaps that lead to a patient injury … It’s tough when the pressure is high and the patient is at risk.

817. Using Probabilistic Risk Assessment to Model Medication System Failures in Long-term Care Facilities (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Comden.pdf
     January 01, 2003 - as increased medication-borrowing behavior to avoid citations for “drug not available” or the time pressures … Assessing patient safety risk before the injury occurs: an introduction to socio- technical probabilistic

818. Final Progress Report: Medication List Consistency When Patients Transition from Hospital to Community (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/21984-Kennelty-report.pdf
     July 31, 2013 - The hospital is a Level One trauma centers for adults and pediatrics in the Midwest. … hospitalizations in the past, living alone, three or more chronic conditions, two or more falls with injury … Section 2) Subjective norm or the pharmacists’ perception of social normative pressures to perform medication … the convenience and advertising, you know, with the quick wait times, that sort of thing, there is pressure

819. Final Progress Report: Medication List Consistency When Patients Transition from Hospital to Community (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/kennelty-report.pdf
     January 01, 2024 - The hospital is a Level One trauma centers for adults and pediatrics in the Midwest. … hospitalizations in the past, living alone, three or more chronic conditions, two or more falls with injury … Section 2) Subjective norm or the pharmacists’ perception of social normative pressures to perform medication … the convenience and advertising, you know, with the quick wait times, that sort of thing, there is pressure

820. Final Progress Report: National Trends in Outpatient Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/stafford-fortmann-report.pdf
     January 01, 2024 - (Thorndike 1998), screening electrocardiogram use, exercise stress testing (Cohen 1999), and blood pressure … as poor diet, physical inactivity, and tobacco or other substance use, unsafe sex, unintentional injury