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821. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
     May 01, 2017 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor

822. AHRQ Safety Program for Perinatal Care: Experiences from the Frontline (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
     May 01, 2017 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor

823. Anticipatory Guidance for Prevention of Stroke in Children with Sickle Cell Disease (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-225-fullreport.pdf
     June 01, 2019 - experience a stroke by 20 years of age; approximately 13 percent show evidence of silent infarcts, that is, injuries … Risk factors for stroke include a history of TIA, elevated systolic blood pressure, elevated steady‐state … These lesions are evidence of brain injury and should prompt evaluation of the child for learning and

824. CHIPRA 209 Report: Neonatal Intensive Care Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-209-fullreport.pdf
     June 01, 2019 - BPD: gentle ventilation strategies, including primary use of continuous positive airway pressure (CPAP … Continuous distending pressure for respiratory distress in preterm infants. … Impact of bronchopulmonary dysplasia, brain injury, and severe retinopathy on the outcome of extremely

825. Experiences From the Frontline: Case Studies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/frontline-cases-studies.pdf
     May 01, 2015 - Root cause analyses of adverse events and near-misses (events that did not produce patient injury) revealed … The AHRQ Patient Safety Indicator 18 (Obstetric Trauma–Vaginal Delivery with Instrument) decreased by … in-house neonatal death, uterine rupture during labor, unplanned maternal admission to ICU, birth trauma … processes at the point of care to include specific maternal parameters, including blood loss, blood pressure … They established a standard process for blood pressure measurement upon admission and during labor to

826. Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/14289-Jack-draft-1.pdf
     January 19, 2005 - goals to (1) assess risks and known hazards to patients in the process of care, leading to preventable injuries … of information for patients in general, but especially to those with low literacy skills, and a low-pressure

827. Final Progress Report: Re-engineering the Hospital Discharge for Patient Safety--Safe Practices Implementation Challenge Grant (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/jack-report.pdf
     January 01, 2024 - goals to (1) assess risks and known hazards to patients in the process of care, leading to preventable injuries … of information for patients in general, but especially to those with low literacy skills, and a low-pressure

828. Best Practices in Public Reporting No. 2: Maximizing Consumer Understanding of Public Comparative Quality Reports: Effective Use of Explanatory Information | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/tools/public-reporting/guide2.html
     June 01, 2017 - medical errors and does not cause harm," which would include measures such as surgical infection rates or injuries … Explanation of Its Purpose and Value The five goals for living well with diabetes (D5): controlling blood pressure

829. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - As Tucker has noted, production pressure may cause health care professionals to participate in “first-order … improving patient safety: “We have been analyzing and creating reports of falls with and without injuries

830. Issues Regarding Identification of Urinary Catheter Use From Medical Records | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/hai/patient-safety-resources/advances-in-hai/hai-article18.html
     August 01, 2018 - Consultation notes commonly describing UCs were from physical medicine and rehabilitation, the wound/ … The pressure to augment income is strong. … mental status, malaise or lethargy † ___ New or worsening incontinence ** ___ For spinal cord injury

831. Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care - Contract No. 290-04-0016 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/information-tech-support-transformation-proactive.pdf
     July 01, 2010 - � “Primary prevention – Prevention strategies that seek to prevent the occurrence of disease or injury … prevent disability by restoring individuals to their optimal level of functioning after a disease or injury … are flagged as potentially having hypertension after a third sequential visit with elevated blood pressure … A graph page can show patient trends for weight and blood pressure, and key labs over a 2-year period … conditions (e.g., identify groups of patients with diabetes and monitor their hemoglobin A1c levels, blood pressure

832. HF Measures For Public Comment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternity.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

833. Maternity Care Performance Measurement Set (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/CHIPRA-BMI-Maternity-Care-Measures.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

834. HF Measures For Public Comment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0082maternity.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

835. HF Measures For Public Comment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0085maternitycare.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

836. HF Measures For Public Comment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0084maternity.pdf
     February 23, 2012 - Larger infants have increased rates of birth trauma, shoulder dystocia, and cesarean delivery. … delivery are at much higher risk for rehospitalization for uterine infection and obstetrical surgical wound … (ACOG, 2006, Level A)  Median episiotomy is associated with higher rates of injury to the anal sphincter … with episiotomy can be considered worse since some proportion of women who would have had lesser injury … Preventing perineal trauma during childbirth: a systematic review.

837. Current State of Diagnostic Safety: Implications for Research, Practice, and Policy - Issue Brief (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dxsafety-current-state.pdf
     January 01, 2024 - that patients with diagnosis-related claims were 2.33 times more likely to die than to have a minor injury … and have been associated with increased medical errors and stress, anxiety, and burnout.113,114 Time pressure … diagnostic safety found the need to prioritize research on system factors, such as workload, time pressure … Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from … Adv Wound Care (New Rochelle). 2013 Dec;2(10):588-592. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3865615

838. Final Progress Report: Improving Medication Management Practices and Care Transitions Through Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/feldman-report.pdf
     January 01, 2024 - items included comorbidities and symptom severity, risk factors, prognosis, therapies, pain status, wounds … medication management module was not mandatory, and other more urgent clinical situations (e.g., a worsened pressure … 1.53 (1.07, 2.19) 0.02 1.49 (1.08, 2.05) 0.01 History of falls (2 or more falls, or any fall with an injury

839. Transitional Care Medication Safety: Stakeholders’ Perspectives | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/liability/corbett.html
     August 01, 2017 - An adverse event is defined as an injury resulting from health care management, rather than the underlying … from a rural hospital recommended “Organize the paperwork with separate categories to clearly define ‘wound

840. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/liability/corbett.html
     August 01, 2017 - An adverse event is defined as an injury resulting from health care management, rather than the underlying … from a rural hospital recommended “Organize the paperwork with separate categories to clearly define ‘wound