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1321. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
      September 01, 2017 - Report data help identify residents with new ADL decline, fall risk, or fall injury, therefore at risk … and Rehab  Managers Weekly huddle to review residents at risk for ADL decline or fall or with fall injury … with stage 2 or above pressure ulcers at risk for infection who potentially require hospitalization/ … Reports provide information about current and changing risks for pressure ulcer healing and can aid root … Discharge diagnoses were dehydration, fall with injury, cellulitis, and angina.

1322. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853902/psn-pdf
      September 27, 2023 - diuresis, diarrhea, and fluid restriction, they ordered blood products and albumin to increase oncotic pressure … psnet.ahrq.gov//#8 resuscitation,” with the added requirement for vasopressors to maintain a mean arterial pressure … perforations.21 Other identified risk factors include older age, presence of comorbidities,22 acute kidney injury

1323. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet
      psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
      January 29, 2021 - diuresis, diarrhea, and fluid restriction, they ordered blood products and albumin to increase oncotic pressure … responsive to fluid resuscitation,” with the added requirement for vasopressors to maintain a mean arterial pressure … perforations. 21 Other identified risk factors include older age, presence of comorbidities, 22 acute kidney injury

1324. Archived: Carotid Artery Stenosis: Screening, 1996 | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening-1996
      January 01, 1996 - important modifiable risk factors are hypertension and smoking. 8 Improved treatment of high blood pressure … An awareness of the diagnosis might motivate patients to modify other risk factors (e.g., high blood pressure … ACAS was small and not conclusive surgery may result in other nonfatal complications (cranial nerve injury

1325. Implement Teamwork and Communication for Perinatal Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
      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, … Example: The nurse says to the doctor, “Doctor, the patient’s blood pressure is dropping; it is 60

1326. In Conversation with…Christopher P. Landrigan, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
      April 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 … March 2, 2011 Extended work duration and the risk of self-reported percutaneous injuries

1327. Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
      May 01, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (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. … 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

1328. Timely Antibiotics for Children With Severe Sepsis or Septic Shock (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-fullreport.pdf
      April 02, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for therapy of the underlying injury once shock is present. … 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

1329. Interventions for Weight Management in Children and Adolescents: Updated Evidence Report and Systematic Review for the USPSTF (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/e9f8a_uGMXxSbBUxpRPkrc
      June 18, 2024 - apnea]), intermediate outcomes (BMI, weight, physical fitness, cardiometabolic outcomes [eg, blood pressure … was phentermine/topiramate, and only at the higher dose level (mean difference for diastolic blood pressure … pressure, fasting glucose levels, and quality of life but had no apparent impact on lipid levels, other … of thyroid tumors, including cancer, as well as pan- creatitis, gallbladder problems, acute kidney injury … prospective study of weight self-perception and blood pressure in adolescents with overweight and obesity

1330. In Conversation with...Joseph Britto, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
      February 01, 2007 - And of course there is increasing pressure on the system to get it right, to not make so many mistakes … Yet the pressures in the market around pay for performance and transparency may conspire to begin stripping … Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, … Rarely, the error may cause injury or death.

1331. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
      June 01, 2005 - a particular patient safety intervention is going to save large numbers of lives or reduce serious injuries … intervention, they referred to any event that resulted in the emergency team being called—low blood pressure … the error caught by their regular physician, others would experience asymptomatic reduction in blood pressure … July 14, 2010 Measurable outcomes of quality improvement in the trauma intensive care

1332. Virtual Patient Advocate to Reduce Ambulatory Adverse Drug Events (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017196-jack-final-report-2011.pdf
      January 01, 2011 - outcomes-assessors rated on an ordinal scale from 1-6 their confidence that medical management caused an injury … (injuries rated 5 or 6 are considered ADEs); (3) outcomes-assessors then rated each AE for ameliorability … the outcomes-assessors categorized the type of each ADE as: adverse drug event, procedure-related injury … For another patient, blood pressure was reviewed in detail, including recent lab test results and goals … (if alert rated as a potential problem or problem needing timely response) n=13: Procedure related injury

1333. A Patient Safety Program & Research Evaluation of U.S. Navy Pharmacy Refill Clinics (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Reige.pdf
      March 01, 2004 - an acute skeletal muscle relaxant medication for nearly a year; it was originally prescribed for injuries … Elderly people are at a higher risk for falls resulting in serious injury, and when a person is dizzy … When an elderly patient falls, serious injury may occur. … Part of the medication renewal process involves checking the patient’s blood pressure or performing

1334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33717/psn-pdf
      September 01, 2011 - Risk managers developed these systems to identify injuries that might lead to litigation and to reduce … pertinent to nursing care, such as medication administration errors, falls, IV infiltrations, and pressure

1335. Final Progress Report: Pursuing Perfection in Pediatric Therapeutics (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/lannon2-report.pdf
      January 01, 2024 - Predict and prevent nephrotoxic medication-associated acute kidney injury in noncritically ill hospitalized … Electronic Health Record Identification of Nephrotoxin Exposure and Associated Acute Kidney Injury. … -55 27803957 2017 NPC-QIC Improvement/outcomes Frank G, Walsh KE, Wooton S, et al Impact of a Pressure … Injury Prevention Bundle in the Solutions for Patient Safety Network Pediatric quality & safety

1336. A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries | PSNet
      psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
      July 23, 2024 - riskier. 13 Babies delivered via cesarean section are at risk for respiratory problems and surgical injury … A 2014 study of women who gave birth found that 14.8% of respondents perceived pressure from a clinician … www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655#:~:text=A%20C%2Dsection%20might%20increase,Wound … Patient-perceived pressure from clinicians for labor induction and cesarean delivery: a population-based

1337. Presentation: Optimize Your Briefings and Debriefings
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_opt_briefings.pptx
      December 01, 2017 - defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury … Serious injury specifically includes loss of limb or function. … Confirm patient identity, site, and procedure Review perfusion plan, including– Cannulation Perfusion pressure … Review the perfusion plan, including cannulation, perfusion pressure goals, temperature, and transfusion … for improvement Ask if instrument, sponge, and needle counts are correct Record name of procedure and wound

1338. N3Veybr4Zdhzfqsw3Erlhe (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/N3VeYbr4ZdhZfqsw3ErLHE
      November 01, 2014 - Mortality from all strokes has decreased sub- stantially over the past 5 decades; improved blood pressure … Cranial nerve injury is another important potential harm; it oc- curred in 3.8% of patients (8 of 211 … The MACE trial reported a 1.1% rate of minor cranial nerve injury in the 36 patients ran- domly assigned … treatment groups in the RCTs were poorly defined and probably did not include the intensive blood pressure

1339. Obesity-Child Executive (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/obesity-child_executive.pdf
      March 31, 2010 - thickness, prevalence of obesity or overweight); clinical outcomes related to obesity (e.g., blood pressure … Adverse effects • Eating disorders, psychosocial outcomes, impact on growth and development, injury … Eating disorders • Psychosocial outcomes, e.g. stigma • Impact on growth and development • Injury … overweight, dietary intake, physical activity, and obesity-related clinical outcomes (e.g., blood pressure … reported some statistically significant desirable effects, predominantly regarding lowered blood pressure

1340. Final Progress Report: Making Acute Care More Patient Centered, Patient Safety Learning Laboratory (PSLL) (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/bates3-report.pdf
      January 01, 2024 - concordance by patients and care team members, and the incidence of patient falls and fall-related injuries … The effect of the intervention on patient falls (dichotomized as fall/no fall) and falls with injury … (dichotomized as falls with injury/no injury) was analyzed using logistic regression estimated via … Scope Inpatient adverse events (AEs) are patient injuries due to medical management that prolong hospitalization … Bowel Regimen, Venous Thromboembolism (VTE) Prophylaxis, Opioid Management, Antibiotic Management, Pressure