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1261. Usability Testing and the Relation of Clinical Information Systems to Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rogers.pdf
      January 01, 2003 - Scenario-based testing also identified workplace performance trade-offs related to time and production pressures … ability to identify impact prior to implementation and to suggest redesign before adverse events or injury … Difficulty in design decisions can more easily be created when “typical” work with its time pressure … a series of often unrelated single tasks (e.g., open a program, save a file), without performance pressure … Software used in health care can prevent patient injury or contribute to it, when usability testing

1262. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33713/psn-pdf
      June 01, 2011 - While the team adjusted the table, it swung loose and the patient fell to the floor but sustained no injury

1263. Appendix III (continued) | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiid.html
      June 01, 2010 - A few are related to the health and welfare of clients, such as injuries and medication errors. … HCBS MS Domains: Unmet Need Populations: Individuals with disabilities, adults with acquired brain injuries … information concerning the number of incidents (abuse and neglect; restraints, crimes against, serious injuries … required data via NCI form titled "NCI Protocol for Reporting Incidents: Abuse and Neglect, Serious Injuries … additional measures under development relate to influenza vaccinations for people with disabilities and pressure

1264. In Conversation With… Sharon K. Inouye, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
      December 01, 2012 - My criteria for neuroimaging are that if someone has a history of head trauma or evidence of bruising … In the absence of any neurologic changes, head trauma, or fever where you think there could be herpes … " similar to other end-organ injuries (e.g., heart attack, acute kidney injury). … As with these other important end-organ injuries, delirium is a clinical event for which prevention and … spontaneous breathing trials (SBT, defined as turning the ventilator settings to continuous positive airway pressure

1265. Financial and Demographic Influences on Medicare Patient Safety Events (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
      January 01, 2004 - Database for Florida from 1996–99 (373,814 discharges at 188 hospitals) to examine whether financial pressure … Shen (2003) examined the effect of financial pressures on patient outcomes and found that financial … pressures adversely affect patient outcomes.7 That study used data from an earlier period (1985–94), … The effect of financial pressure on the quality of care in hospitals. … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

1266. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49400/psn-pdf
      May 01, 2003 - A full code ensued and after a brief time, the patient was stabilized with a blood pressure of 95/55 … or more risk factors identified only one patient with a DVT.(9) A retrospective study of pediatric trauma … Assistant Professor of Pediatrics (Anaesthesia), Harvard Medical School Chair, Pediatric Acute Lung Injury … Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases.

1267. Chronic-Urinary-Retention Research (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/chronic-urinary-retention_research.pdf
      September 01, 2014 - (7 percent), and other conditions such as stroke or traumatic brain injury (29 percent). … Journal of Wound, Ostomy, & Continence Nursing. 2007 May- Jun;34(3):289-96. PMID 17505249. … disease and a history of stroke or myocardial infarction in the previous 6 months; resting blood pressure … citrate Control: placebo Definition/etiology max flow rate <15ml/min, max urethral closure pressure … Score; LUTS = lower urinary tract symptoms; MS = multiple sclerosis; MUCP = maximal urethral closure pressure

1268. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
      January 01, 2004 - With disease, injury, or illness, the diagnosis is often obvious and may involve no more than simple … Coercive pressures may drive a particular agenda that is not congruent with good decisionmaking. … For example, team pressures to lower door-to-needle times for thrombolytic therapy in the context of … affective error by changing systemic features: decreased reliance on memory, minimization of time pressure … Minimize time pressures Provide adequate time for quality decisionmaking.

1269. Disposition of Comments for Treatment of Glaucoma: Comparative Effectiveness (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/glaucoma-treatment_disposition-comments.pdf
      April 01, 2012 - In this study, intraocular pressure reduction was similar between the groups. … Krupin T, Reviewer #3n JM, Greenfield DS, et al; Low-Pressure Glaucoma Study Group. … Public comment/ AAO-AGS Results Key Question3b It is important to remember that target intraocular pressures … Likewise, the conclusion that use of MMC results in lower intraocular pressures needs to be considered … with glaucoma includes increased risk of nursing home admission, depression, falls and/or accidents, injury

1270. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853080/psn-pdf
      August 30, 2023 - of Nursing Quality Indicators showed low incidence of catheter-associated urinary tract infections, pressure … injuries, deep vein thrombosis, and central-line associated blood stream infection.1 In terms of patient

1271. DEcIDE 32: The Incident User Design in Comparative Effectiveness Research (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/incident-user-design_research.pdf
      May 01, 2012 - noted above, Psaty and colleagues went to exceptional effort to obtain patients’ pretreatment blood pressure … index date that determined current drug use.8 Even with that exceptional effort, pretreatment blood pressure … Had Psaty and colleagues adjusted for patients’ most recent blood pressure values, they would have biased … the comparisons between classes of antihypertensive drugs because the most recent blood pressure value … Injury Prev 2002;8:276-9. 40. Glynn RJ, Schneeweiss S, Stürmer T.

1272. Disposition of Comments for Technical Brief 24 Resident Safety Practices (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/nursing-home-safety_disposition-comments.pdf
      May 27, 2016 - Falls yes but infections, pressure ulcers? … (e.g., hip fracture and brain injury), and deaths subsequent to these injuries. … Peer reviewer #5 Findings GQ1c—The discussion on pressure ulcers is insufficient. … Studies on injuries and deaths subsequent to injuries as a result of resident-to-resident altercations … Falls with Injury.

1273. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet
      psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
      March 31, 2021 - when) treated in a timely and aggressive manner. 1 Rarely, NSTIs can occur as a severe postoperative wound … If he or she described a ‘wound infection in a plastic surgery patient,’ for example, this would have … Burnout Physician burnout (also referred to as “moral injury”) is an ongoing topic of discussion in medicine … survey of subspecialty surgeons: “while EGS surgeons appear to meet [a clinical] need and relieve some pressure … Journal of Trauma and Acute Care Surgery . 2018 July;85(1):208-214.

1274. Screening and Interventions for Childhood Overweight: A Systematic Review (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/6desD2XJCQKF8ZDPMS-NU_
      July 01, 2005 - Blood pressure was not improved, and in 10 some cases increased blood pressure was … stigmatization, binging or purging behaviors, eating disorders, suppressed growth, or exercise-induced injuries … Childhood risk factors for high adult blood pressure: the Muscatine Study. … Childhood predictors for high adult blood pressure. The Muscatine Study. … Alterations in anthropometric blood pressure and serum lipoprotein variables.

1275. Error Producing Conditions in the Intensive Care Unit (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
      February 26, 2008 - Time pressure in error detection. 3. Low signal-to-noise ratio. 4. … percent), the surgical ICU (8 percent), the neurological critical care unit (8 percent), and the burn-trauma … 38 ICU workplace (%) Medical 68 Thoracic 12 Surgical 8 Neurological critical care 8 Burn-trauma … Given the problems outlined above, it is no surprise to find that under time pressure, the operation … Preventing ventilator-related death and injuries.

1276. Hold the tPA | PSNet
      psnet.ahrq.gov/web-mm/hold-tpa
      July 29, 2020 - window, use of antithrombotic therapy within 24 hours of tPA administration, and failure to follow blood pressure … Same Author(s) A randomized trial of a multifactorial strategy to prevent serious fall injuries

1277. Final Progress Report: Evaluating the Impact of Simulated Team Training on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/scott-report.pdf
      January 01, 2024 - Use the ambulatory surgical setting as a model to better understand risks and injuries and to focus … University of Michigan, complications may occur in nearly 13% of cases.4 Preventable healthcare-related injuries … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … by the team; and 3) Hypercarbia – the patient becomes hypercarbic with increased peak inspiratory pressures … and implement team training curricula regarding other domains, such as rare event crises in the OR, trauma

1278. Methods – Applying HCUP Quality Indicators (pdf file)
      hcup-us.ahrq.gov/reports/methods/2019-01.pdf
      January 01, 2019 - • ED visits for injuries. … ED utilization for injuries was reported by trauma level and by age, sex, community income, urban-rural … PDI11 Reclosure of postoperative abdominal wound dehiscence per 1,000 abdominopelvic-surgery admissions … PSI14 Reclosure of postoperative abdominal wound dehiscence per 1,000 abdominopelvic-surgery admissions … PSI17 Birth trauma - injury to neonate per 1,000 live births Consistent with the AHRQ PSI software

1279. Disposition of Comments Report for Comparative Effectiveness Review #68 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/nppv-respiratory-failure_disposition-comments.pdf
      July 01, 2012 - Noninvasive Positive–Pressure Ventilation (NPPV) for Acute Respiratory Failure. … When expiratory pressure is combined with higher inspiratory pressure in bilevel modes, it is not continuous … There are in fact two pressures: a continuous level that is periodically augmented by additional inspiratory … pressure. … Role of noninvasive ventilation in acute lung injury/acute respiratory distress syndrome: a proportion

1280. Electronic Medication Adherence Reporting and Feedback During Care Transitions - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024587-schnipper-final-report-2019.pdf
      January 01, 2019 - Several studies have shown that post-discharge adverse drug events (ADEs, injury due to a medication … evaluated in the transitions setting, where there are unique logistical challenges, e.g., due to time pressures … of disease control (Table 4a and 4b), those assigned to the smart pillbox overall had better blood pressure … control, especially diastolic blood pressure (arguably the more important of the two measures) in fully … goal of < 130 mmHg or decrease to that goal if not at goal at baseline b Maintain diastolic blood pressure