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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/sustainability.html
January 01, 2013 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … The team implemented the program in two pilot units (medical intensive care and trauma/orthopedics),
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www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm7.html
October 01, 2014 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … self-reporting is an invalid and unreliable way to collect data on clinical indicator values, such as blood pressure … Blood pressure test at every continuing care visit. … A State interested in tracking pressure ulcers in its Supplemental Security Income (SSI) population, … contains hybrid specifications for measures such as cholesterol management, controlling high blood pressure
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/vtguide/guide5.html
October 01, 2022 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … created VTE prevention decision algorithms for 16 distinct service groups (medicine, general surgery, trauma … hospital discharge without any change in major bleeding or all-cause mortality. 7 Implementation on trauma
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/ascwebcast0715_transcript.pdf
September 01, 2015 - our overall efforts in patient safety, and as part of the National Action Plan for health-associated
injuries … Smith, Slide 23
And the area with the most room for improvement was Staffing, Work Pressure and Pace … Smith, Slide 25
The two bottom-performing items were from Staff Training and the Staffing, Work Pressure … And you can see that for Staffing, Work Pressure and Pace it was a 94 percent positive compared to a … Brown, Slide 44
Our second area of focus was Staffing, Work Pressure and Pace, and our result was 55
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www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm8.html
October 01, 2014 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … It significantly affected measures such as blood pressure, lipid screening and levels, HbA1c screening … Blood pressure.
Lipid (cholesterol and triglyceride) levels. … Of the intervention categories, in-person care management, which lowered HbA1c levels, blood pressure … Nurse case management improves blood pressure, emotional distress and diabetes complication screening
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - Eventually, they are able to re-establish a normal heart rate, blood pressure, and adequate blood
oxygen … During her procedure, her heart rate, blood pressure, and oxygen level were monitored. … During a part of
the procedure, we became aware that her heart rate, blood pressure, and oxygen level … First off, right now Mary
is stable; her heart rate, blood pressure, and oxygen level are all in normal … We also don’t know right now if she has
suffered any injury from what happened, but we will check her
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … Whenever pressure builds up, my supervisor/manager wants us to
work faster, even if it means taking
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
March 22, 2017 - • “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events … Whenever pressure builds up, my supervisor/manager wants us to
work faster, even if it means taking
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool1a.docx
January 01, 2004 - “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events resulting … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
September 28, 2016 - private-public partnerships to:
• Identify the causes of preventable health care
errors and patient injury … approximately $19.8 billion in health care costs
were saved from 2010 to 2014
Adverse
Drug
Events
Pressure … • Unsafe care causes 43 million
injuries a year and the loss
of 23 million disability-
adjusted
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www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/implement-fac-guide.html
July 01, 2023 - Slide 6: Root Causes of Maternal and Perinatal Deaths and Injuries 2004-2012
Say:
Human factors … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are—
Assessment.
Leadership. … Example:
The nurse says to the doctor, "Doctor, the patient's blood pressure is dropping; it is 60/
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-192-fullreport.pdf
November 01, 2019 - These complications include
compromised airway, hypoxia leading to central nervous system injury, and … • Signs or symptoms of increased intracranial pressure (Table 10 [=IMG11]; see Supporting
Documents … • Signs or symptoms of increased intracranial pressure.
• Abnormal neurologic exam. … These risks include dental trauma;
airway edema (swelling of the windpipe); vocal cord spasm or injury … Incidental findings in children with blunt head trauma
evaluated with cranial CT scans.
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.html
July 01, 2022 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI
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www.qualitymeasures.ahrq.gov/health-literacy/professional-training/lepguide/app-b.html
September 01, 2020 - About 30 minutes later, he begins to develop some chest pressure, which he had not noticed before. … prevented the severe allergic reaction and allowed him to receive the angioplasty that could have prevented injury
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.docx
May 01, 2017 - communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are—
Assessment,
Leadership,
Information … Example:
The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60/40
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
June 16, 2017 - number of medications that could cause sedation, confusion, impaired balance, or orthostatic blood pressure … Carefully assess patients for any injuries in a systematic way.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urine-culturing-notes.docx
April 01, 2022 - Her temperature is 100.8 degrees Fahrenheit, heart rate 130, respiratory rate 22, and blood pressure … mistakenly considered an unavoidable “cost of doing business” instead of understood as avoidable, tragic injury
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-fullreport.pdf
June 01, 2018 - (hypotension), as children often
maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for treating underlying injury once shock is present. … , central venous pressure, urine output, metabolic status, and
peripheral perfusion (Rooney, Nadel, … Because children often maintain their blood pressure
until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-31-facilitating-panel-management.pdf
September 01, 2015 - acute care centers—services rendered to
patients needing urgent medical attention (e.g., infection, injuries … The registry can also identify patients not in control of HbA1c, LDL, or blood
pressure, patients who … Other information may need to be input by someone
in the clinic, for example, blood pressure, weight … The Panel Manager may also have the job to enter
data into the registry (like blood pressures) and to … Which of these patients would you call to schedule a group blood pressure clinic
appointment?
b.
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www.qualitymeasures.ahrq.gov/news/blog/ahrqviews/defining-new-ahrq.html
January 01, 2021 - HAC events amount to more than $28 billion in excess healthcare costs, including pressure ulcers ($9.9 … nurses and other healthcare professionals remains a significant and troubling issue, as do workplace injuries