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1301. 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

1302. 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.

1303. 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

1304. 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

1305. 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

1306. 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.

1307. 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

1308. 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.

1309. 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.

1310. 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

1311. 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

1312. 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.

1313. 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

1314. Effectiveness of Weight Management Interventions in Children: A Targeted Systematic Review for the USPSTF (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/b5LjDb3-UoPV8LEWavJWB8
      February 01, 2010 - Chanoine et al, however, reported a small reduction in diastolic blood pressure (not systolic blood pressure … Two other trials41,42 that did not meet treat- ment inclusion criteria reported injury rates among obese … evidence that behavioral intervention programs may be harm- ful, except they perhaps mildly in- crease injury … reported for the intervention groups (n � 114), whereas no children in the control groups reported injuries … baseline percent overweight, and mid- parental height.43 We also found little risk of exercise-induced injuries

1315. Premature Closure: Was It Just Syncope? | PSNet
      psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
      February 10, 2021 - His initial vital signs in the ED were notable for a systolic blood pressure in the 100s and a heart … This suggests that the clinicians initially considered trauma but prematurely narrowed their focus to … additional history-taking may have revealed the patient’s recent history of falls with repeated closed head injuries … “Has this patient suffered recent head trauma or is this patient at increased risk of head trauma?”) … June 14, 2023 WebM&M Cases Under Pressure: Delayed

1316. 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

1317. 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

1318. 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

1319. ___APS-Def_Public.book (pdf file)
      hcup-us.ahrq.gov/db/nation/nis/APS-DRGs%20V22%20Definitions%20Manual.pdf
      April 01, 2006 - Ventilation - < 96 Hours 9672 Continuous Mechanical Ventilation - 96+ Hours 9390 Continuous Positive Airway Pressure … 440 440 WOUND DEBRIDEMENTS FOR INJURIES 441 441 HAND PROCEDURES FOR INJURIES 442 442 OTHER O.R PROCEDURES … FOR INJURIES 443 442 OTHER O.R PROCEDURES FOR INJURIES 444 444 TRAUMATIC INJURY AGE >17 445 444 … TRAUMATIC INJURY AGE >17 446 446 TRAUMATIC INJURY AGE 0-17 447 447 ALLERGIC REACTIONS AGE >17 448 … ,POISON&TOXIC EFFECT DX 455 454 OTH INJURY,POISON&TOXIC EFFECT DX 461 461 O.R.

1320. CER 226: Evidence summary_Labor Dystocia (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/Evidence%20Summary_2.pdf
      May 01, 2020 - amniotomy, supportive care measures, epidural analgesia, frequency of cervical examination, intrauterine pressure … since cesarean delivery itself increases the risk of maternal hemorrhage, venous thromboembolism, and injury … Table W summarizes the SOE for intrauterine pressure catheters versus external monitoring. … Intrauterine pressure catheters versus external monitoring: Evidence summary in women of unspecified … Low (one study) Neonatal Outcomes – Neonatal Death, major birth injury, respiratory distress transient