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1261. Intravenous Infusion Safety Initiative: Collaboration, Evidence-Based Best Practices, and “Smart” Technology Help Avert High-Risk Adverse Drug Events and Improve Patient Outcomes (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Maddox_38.pdf
      March 26, 2008 - leading cause of patient harm is medication errors, which account for almost 20 percent of medical injuries … .1 Twenty-eight percent of medication-related injuries (adverse drug events, ADEs) are considered preventable … Anesthesia Patient Safety Foundation (APSF) notes a significant, underappreciated risk of serious injury … with other medication errors, IV infusion programming errors have a greater likelihood of causing injury … programmed, appropriate doses of opiates can suppress respiration and decrease heart rate and blood pressure

1262. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet
      psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
      March 01, 2004 - preoperative period but suffered a pulseless electrical activity arrest in the operating room at the time of wound … 1997 data from the National Inpatient Sample Excludes patients with any code for cancer, trauma … Excludes patients with any diagnosis code for drug dependence, abuse of drugs, or self-inflicted injury … Decubitus ulcer Pressure sores in patients hospitalized for 4 days or longer Discharges … diagnosis among all surgical discharges Excludes patients who have principal diagnosis codes for trauma

1263. Spinal Epidural Abscess | PSNet
      psnet.ahrq.gov/web-mm/spinal-epidural-abscess
      November 13, 2019 - The most common risk factors for SEA are diabetes mellitus, intravenous drug use, trauma, and alcohol … Yi Lu, MD, PhD Director, Neurosurgical Trauma Co-director, Adult Deformity and Scoliosis Surgery Assistant … March 1, 2005 WebM&M Cases Missing the Point—Eye Injury … More Related Resources WebM&M Cases Under Pressure … Pitfalls February 1, 2010 WebM&M Cases Missing Trauma

1264. Appendix D. Falls Engineer Instructions | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapd.html
      December 01, 2017 - Engineer Instructions The Falls Management Program is designed to prevent falls and injuries … Fill to the pressure recommended on the side of the tire. … Instructions: If the brake lever does not bite 1/8 inch into the tire, it may be because the tire pressure

1265. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-pediatric-safety-refs.html
      August 01, 2023 - Identification of children at very low risk of clinically-important brain injuries after head trauma: … Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury … Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE … Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. … The use of telemedicine in the care of the pediatric trauma patient. Semin Pediatr Surg .

1266. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
      January 01, 2024 - Results: Major hazards identified included time pressure, lack of coordination between physician and … hazards. 18,19,33 3 It is well recognized in safety engineering that the heart of safety lies not in injuries … A hazard is anything that increases the probability of errors or of patient/ employee injury and is … -Sutures removed too soon after minor surgical procedure and wound dehiscence, which requires 6 weeks … Patient gets dizzy after first dose, falls, but no injury and stops med.

1267. Disposition of Comments Report for Pharmacologic and Mechanical Prophylaxis of Venous Thromboembolism Among Special Populations (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/vte-prophyalaxis_disposition-comments.pdf
      May 29, 2013 - risk factors for VTE in burn patients including burn area but also including age, BMI, concomitant injuries … We extracted information on specific injury scores by region ( Head/neck AIS ) when it was available … patients WITHOUT traumatic brain injury. … Additionally, there are other high-risk sub-groups within the trauma population: spinal injury, multiple … stockings have 18mmHg compression for bedridden patients Compression stockings are optimal if ankle pressure

1268. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857059/psn-pdf
      November 29, 2023 - complications and the time period for ascertainment.11,14,17,18 The most common complications are wound … bumper” syndrome occurs in about 1-4% of cases6,9,14 when the PEG tube’s internal bumper causes focal pressure … Liver injury during PEG tube placement: report of two cases. … Trauma transitional care coordination: a mature system at work. … J Trauma Acute Care Surg. 2018;84(5):711-717. [Available at 48.

1269. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33739/psn-pdf
      October 01, 2012 - single-bed patient rooms with high-efficiency particulate air filters and with negative or positive pressure … and the design and location of hazards like furniture—can contribute to patient falls and associated injuries

1270. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49518/psn-pdf
      August 01, 2006 - add-on visits, and unexpected staff absences could all have increased the day's workload and production pressure … Insulin errors and injuries are common among hospitalized patients.(4-9) The risk of treatment-related

1271. Advances in Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advances/index.html
      July 01, 2022 - Reige Surveillance Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM … Song, Tracey Pritchett Developing a Veterans Health Administration (VHA) Serious Injury Surveillance … Jaser, Nancy Safer, Paul Davern Medical Injury Identification Using Hospital Discharge Data (   PDF … Nozick Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure

1272. Primary Care Practice Facilitation Curriculum Module 31: Facilitating Panel Management (pdf file)
      www.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.

1273. Documentation of Heart Rate During Fluid Resuscitation for Children With Severe Sepsis or Septic Shock (pdf file)
      www.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

1274. Central Line Clot | PSNet
      psnet.ahrq.gov/web-mm/central-line-clot
      August 04, 2021 - 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.

1275. 7.  Appendix C: Additional Tables by Topic Area | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2024-annual-report/appendix-c.html
      May 01, 2024 - Appendix D: Grant Summaries P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … program that supports patients discharged from the hospital to home after an episode of acute kidney injury … Prioritizing Quality Improvement for the Treatment of Psychiatric Disturbances Following Traumatic Brain Injury … support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure … practice facilitation would improve the use of a hypertension-focused CDS to effectively improve blood pressure

1276. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
      January 01, 2024 - Only half of basic care processes are provided as recommended, and injuries due to medical errors (preventable … electronic health records with computerized provider order entry (CPOE), which may reduce patient injuries … Conclusions: In hospital-related settings, implementing CPOE is associated with >50% decline in patient injuries … Cost Implications of Improving Blood Pressure Management among U.S. Adults.

1277. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
      January 01, 2025 - states, however; for example, abuse incidents are taken very seriously, but falls, other incidents, and pressure … events or medication errors; resident altercations or other types of abuse; and non-fall related injuries … Compared to 38.5% surveyor visits for burns and 22.7% for pressure ulcers, the numbers are fairly low … The relationship between physical restraint removal and falls and injuries among nursing home residents … ., dispensing, administration, adverse drug event) 27 17.3 6.3 69.3 7.1 24 12.5 4.2 66.7 16.7 Pressure

1278. Implement-Facilitator-Guide (doc file)
      www.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

1279. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33611/psn-pdf
      July 01, 2005 - However, if you believe that these kinds of schedules actually prevent injuries due to medical errors … There has been pressure within the nursing community to keep shifts limited because of data, going back

1280. Unique Challenges in Approaching Diagnostic Safety in Older Adults | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults2.html
      September 01, 2024 - presented 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