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841. Redesigning Systems To Improve Teamwork and Quality for Hospitalized Patients: RESET Project Implementation Guide (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reset-guide.pdf
     January 01, 2020 - priorities can threaten interventions, including hospital mergers, leadership turnover and financial pressures … report many types of adverse events (e.g., catheter- associated urinary tract infections, falls with injury … ordered (e.g., subcutaneous heparin, sequential compression device) • Diarrhea – present or absent • Pressure … ulcer risk – As assessed by the Braden score; includes whether any pressure ulcers are present

842. Making Informed Consent an Informed Choice: Training for Health Care Professionals Audio Script | Agency for Healthcare Research and Quality
     www.ahrq.gov/health-literacy/professional-training/informed-choice/audio-script.html
     September 01, 2020 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don't think I could forgive myself if he wound up dying of meningitis because we didn't finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent form

843. Making Informed Consent an Informed Choice: (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/audio-script-healthcare-professionals-training.pdf
     January 18, 2017 - The final challenge is the time pressure we all face. … Some goals may be long-term, such as reducing the risk of future injury or illness, or living as long … Mom: I don’t think I could forgive myself if he wound up dying of meningitis because we didn’t finish … Non-invasive routine care, such as taking blood pressure, is usually covered by the blanket consent

844. Promote-Toolkit 508 (pdf file)
     www.ahrq.gov/downloads/monahrq/pdf/promote-toolkit_508.pdf
     September 22, 2014 - Melanoma/Skin Cancer Detection and Prevention Month Older Americans Mental Health Week High Blood Pressure … Hepatitis Day Skin Cancer Awareness Month World No Tobacco Day Teen Pregnancy Prevention Month Trauma … Scleroderma Awareness Month Men’s Health Week July Monthly Observances Daily/Weekly Observances Eye Injury … Daily/Weekly Observances American Heart Walk Bone and Joint Decade National Awareness Week Brain Injury

845. Improving Hospital Inpatient Nursing Care: A Case Study of One Hospital's Intervention to Improve the Patient's Care Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/WR_751_AHRQ_Quigley_08_26_10.pdf
     April 01, 2010 - There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … • Don’t let initial pushback from stakeholders or external pressures derail QI efforts; stay focused … specialized intensive care units, state-of-the-art inpatient and outpatient operating suites, a Level-1 trauma … There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … medical doctor referrals to hospital specialists • Hospital workforce data o Vacancy rate o Workplace injuries

846. Improving Hospital Inpatient Nursing Care: A Case Study of One Hospital's Intervention to Improve the Patient's Care Experience (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/compare/WR_751_AHRQ_Quigley_08_26_10.pdf
     April 01, 2010 - There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … • Don’t let initial pushback from stakeholders or external pressures derail QI efforts; stay focused … specialized intensive care units, state-of-the-art inpatient and outpatient operating suites, a Level-1 trauma … There had been minor setbacks in the initial timeline due to threats of nursing strikes and pressures … medical doctor referrals to hospital specialists • Hospital workforce data o Vacancy rate o Workplace injuries

847. Documenting Diagnosis: Exploring the Impact of Electronic Health Records on Diagnostic Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/diagnostic/resources/issue-briefs/dxsafety-ehr-impact.pdf
     August 01, 2024 - Furthermore, because hospitals are reimbursed based on diagnosis-related groups, they face financial pressures … test results, notes on the wrong patient, and errors on which side of the body was the site of the injury

848. Final Progress Report: Targeted Delivery of Multiparametric Telemetry Clinical Messages to Mitigate Alarm Fatigue - PERSEUS (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/kobayashi-report.pdf
     January 01, 2024 - study site was Rhode Island Hospital, a 719-bed nonprofit tertiary care referral facility and Level-I trauma … settings, including EKG/heart rate (HR), respiratory rate (RR), pulse oximetry (SpO2), noninvasive blood pressure … of (de-identified) physiologic datastreams from thousands of live patients with varying illnesses, injuries

849. Final Progress Report: Risk-Informed Interventions in Community Pharmacy: Implementation and Evaluation (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/cohen2-report.pdf
     January 01, 2024 - High-alert medications bear a heightened risk of causing patient injury when they are misused.1 The … demonstrated a clear link between patient counseling and positive clinical outcomes, such as blood pressure … Assessing patient safety risk before the injury occurs: an introduction to socio- technical probabilistic

850. Diagnostic error in mental health: a review (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-mental-health-bmjqs.pdf
     April 15, 2024 - Despite the importance of effective data gathering and synthesis, time pressures, competing priorities … J Trauma Dissociation 2017;18:233–47. 31 Sheehan DV, Lecrubier Y, Sheehan KH, et al. … procedures: are diagnosticians influenced by the narrative fallacy when assessing the psychological injuries … of trauma victims Psychol Inj Law 2016;9:265–71. 54 Jenkins MM, Youngstrom EA.

851. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
     January 01, 2024 - to using the ASIPS reporting system included time, understanding what to report, and the constant pressures … Participants were recruited from a statewide post- injury program run by an ASIPS collaborator (COPIC … Two types of trauma (physical and emotional) were expected and found. … collaboratively helped both patients and providers with patients’ emotional, physical, and financial trauma

852. Final Progress Report: Clinical Decision Support Simulations for Medication Administration Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/moss-berner-report.pdf
     January 01, 2024 - Other data, such as heart rate or blood pressure values pushed as alerts when values are inconsistent … Use of a human patient simulator in the development of resident trauma management skills. … The Journal of Trauma, Injury, Infection and Critical Care. 2001;51(1):17-21. 69.

853. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
     January 01, 2025 - Medication Errors and Injuries. … familiarity with workspace, providers or devices; unwillingness to collaborate; and uncertainty, time pressures

854. Final progress Report: Improving Over-the-Counter Medication Safety for Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/2024-03/chui-report.pdf
     January 01, 2024 - (ibuprofen, naproxen, aspirin) due to the increased risk of gastrointestinal bleeding, high blood pressure … , and kidney injury.

855. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     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.

856. Final Progress Report: Risk Models To Improve Long-Term Care Medication Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/higginson-report.pdf
     January 01, 2024 - and clinical (renal, liver function, or other recent lab test results and monitoring data like blood pressures … actions (i.e., increased 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

857. Evaluation and Research on Antimicrobial Stewardship's Effect on Clostridium difficile (ERASE C. difficile) Project: toolkit (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/cdifftoolkit.pdf
     September 01, 2012 - The guidelines also call for a periodic review because sensitivities could again change as selective pressure … Source: Developed by AHRQ Pressure Ulcer Prevention Toolkit project team. … STEP 5: Epidemiologic Surveillance With time and selective pressure, resistance patterns will change … premenopausal, nonpregnant), diabetics, elderly people, nursing home residents, or patients with spinal cord injury

858. Treatment Strategies for Patients with Lower Extremity Chronic Venous Disease (LECVD): Disposition of Comments (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/comments/lecvd-comments.pdf
     April 01, 2017 - requires exposure to iodinated contrast (with all known risks, including allergy/anaphylaxis, renal injury … Care, Society for Vascular Surgery/American Venous Forum, Wound Healing Society and Wound Ostomy … The impact of telemedicine on outcomes of chronic wounds in the home-care setting. … Managing wound care outcomes.Ostomy Wound Manage. 2005 Apr;51(4):54-6, 58, 59 passim. 6. Lal BK. … Cost and cost effectiveness of venous and pressure ulcer protocols of care.

859. Final Progress Report: Leveraging Existing Assessments of Risk Now (LEARN) Final Report (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/woods2-report.pdf
     January 01, 2025 - The outcomes for pediatric trauma patients treated at children’s hospitals are significantly more favorable … otitis media, and viral syndromes.1 For older children, the most common diagnoses are superficial injury … improved information with respect to error, error risk, and approaches to reduce errors in emergency and trauma

860. Final Progress Report: Patient-Centric Risk Model for Medication Safety During Care Transitions (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurses-report.pdf
     January 01, 2024 - in community settings accounted for 2.5-11.2% of all emergency department visits with unintentional injuries … Monitor medication effects: measure, document, and track self-monitoring values (e.g., blood pressure