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1341. NAA National Webinar July 2024 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/slides-healthcare-safer-by-design.pdf
      August 20, 2024 - Use of an ADC’s override feature should be routinely tracked and monitored. 2023 #6 Inflatable Pressure … ©2024 ECRI | ECRI Confidential47 Surgical Fire Response • Immediate action • Mitigate risk of injury

1342. Buprenorphine and the Medically Ill Patient | PSNet
      psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
      August 20, 2018 - On physical examination, abnormal findings included dilated pupils, elevated heart rate and blood pressure … Injury Prevention and Control Policy Impact: Prescription Painkiller Overdoses.

1343. The Other Side | PSNet
      psnet.ahrq.gov/web-mm/other-side
      May 01, 2007 - is increased when multiple procedures are performed on the same patient, when a team is under time pressure … Error disclosure for patients, however, is merely the first step in a long process of adjustment to an injury

1344. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
      January 01, 2024 - On arrival at the ED, he was afebrile, heart rate was 98 beats per minute (bpm), blood pressure was 103 … laboratories, especially in busy clinical settings such as the ED.2–4 Hemolysis is a generalized process of injury

1345. Who Nose Where the Airway Is? | PSNet
      psnet.ahrq.gov/web-mm/who-nose-where-airway
      May 01, 2016 - how a safety pin could be aspirated, or a non-deformable endotracheal tube connector might cause a pressure … injury to the nares if left in place for more than a brief period.

1346. One Bronchoscopy, Two Errors | PSNet
      psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
      December 09, 2020 - Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … Infusion July 31, 2023 WebM&M Cases Under Pressure

1347. 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

1348. Behavioral Counseling Research and Evidence-Based Practice Recommendations: U.S. Preventive Services Task Force Perspectives | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/behavioral-counseling-research-and-evidence-based-practice-recommendations-us-preventive-services-task-force-perspectives
      March 01, 2014 - example, from alcohol misuse to illicit substance use or from weight control to disordered eating) or injuries … recent meta-analysis of physical activity trials reported an increase in risk factors (such as blood pressure … Even the assessment of intermediate biometric risk factors, such as lipid level, blood pressure, and … Further, national longitudinal studies that include biometric assessments, such as blood pressure, blood

1349. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care | PSNet
      psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
      February 24, 2022 - Dental care providers are advised to: If possible, perform procedures in a negative pressure room … 6 feet apart, especially in counties with substantial or high transmission. 25 Using a negative pressure … create several challenges, including the desire to limit exposure to patients, fatigue, burnout, and pressure … care. 66 Managing necessary deviations from well-rehearsed practice, while under additional budgetary pressures … Remote diagnosis of traumatic dental injuries using digital photographs captured via a mobile phone.

1350. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
      May 01, 2017 - fetal criteria for procedures that increase risk for cord prolapse47 such as— amniotomy intrauterine pressure … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

1351. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
      January 01, 2024 - The report estimated more than a million injuries and nearly 100,000 deaths attributable to medical … medication opportunities (not on an indicated med); (4) failed intermediate outcomes – e.g., high blood pressures … with CHF who are euvolemic (compensated) and on a low dose of an ACE inhibitor with systolic blood pressure … of 110, diastolic blood pressure of 80, and a heart rate of 76, adding a beta blocker is the next most

1352. “Near-miss” Reporting System Development and Implications for Human Subjects Protection (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Murff.pdf
      January 01, 2004 - Several case reports suggest that these extrinsic risks do, in fact, exert significant pressures on … near miss” represents the identification of a potential safety problem, prior to it resulting in an injury … Typically the same system failures that might have resulted in an injury also are present in a near … patient safety can be improved by identifying latent failure prior to the occurrence of a catastrophic injury … Because an injury has not occurred, liability is limited.

1353. 6Ngc3Byq9Jeby Pwyvd6Or (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/6Ngc3byQ9jeBy_pwyvD6or
      September 01, 2014 - Other harms of inter- ventions included myocardial infarction, nerve injury, and hema- toma. … At follow-up in 2002 or 2003, mean blood pressure was 148/79 mm Hg in both groups (41). § 2.9% (44 of … nerve injuries with complete functional recovery. … The Mayo Asymptomatic Carotid Endarterectomy study reported a 1.1% rate of minor cranial nerve injury … important harms, such as nonfatal MI, per- manent cranial nerve damage, pulmonary embolism, pneu- monia, wound

1354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837660/psn-pdf
      July 08, 2022 - The trauma team was called to assist and the patient was given additional sedation and opioid analgesia … The trauma surgeon then manipulated both TMJs and was finally able to unloose the locked jaw. … diagnosis and a physician experienced in reducing the TMJ should be consulted to minimize the risk of injury … Placing staff under too much time pressure can, at times, be counterproductive and can adversely affect

1355. Advancing Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advancing/index.html
      July 01, 2022 - private-public partnerships to: (1) identify the causes of preventable health care errors and patient injury … By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

1356. Development of a Screening Tool for Safe Wheelchair Seating (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Gavin.pdf
      January 01, 2001 - systems do not fit the individual needs of nursing homes residents, many problems can become evident: pressure … diagnosis, cognitive status, communication ability, sensation level, skin integrity (presence/absence of pressure … reductions (e.g., staff time saved if residents could self-propel, elimination of repositioning needs, injury … Nursing home wheelchair users: seat comfort and peak pressures [unpublished doctoral thesis].

1357. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
      February 01, 2007 - Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, … Rarely, the error may cause injury or death. … 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

1358. Screening for Obesity in Children and Adolescents: USPSTF Recommendations Statement (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/PdBbRgWKPMbHfeQeHkM242
      February 01, 2010 - Adverse effects included elevated heart rate, elevated blood pressure, and adverse gastrointestinal effects … high-intensity comprehensive interventions.15 However, decreases in cardiovascular risk factors (eg, blood pressure … Other harms, such as risk of exercise-induced injuries, were con- sidered minimal.

1359. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60328/psn-pdf
      May 27, 2020 - depression, of which 77% resulted in severe brain damage or death.13 Most of these opioid-related injuries … oximetry (SpO2) to monitor patient oxygenation and ventilation.31 Capnography measures the partial pressure … Patients Receiving Opioid PCA Monitoring Component Assessment Types Vital Signs Heart Rate Blood Pressure

1360. The New York Model: Root Cause Analysis Driving Patient Safety Initiative to Ensure Correct Surgical and Invasive Procedures (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Faltz_56.pdf
      March 27, 2008 - identification, orientation/training, use of available information, site marking, “time out,” and time pressures … Although a minority of these events result in significant harm to patients,1 major injuries and death … • Production/time pressures, including case urgency.