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1381. 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

1382. 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

1383. 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.

1384. 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.

1385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49639/psn-pdf
      November 01, 2011 - On further history, he revealed that he had recently increased his beta- blocker, a blood pressure medication … In case of injury, there may have been no attempt at recovery, or the attempts may have been unsuccessful

1386. 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

1387. 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.

1388. 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

1389. 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

1390. 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

1391. Archived: Evidence Summary: Screening for Multifactorial Dyslipidemia: Lipid Disorders in Children and Adolescents: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary-screening-for-multifactorial-dyslipidemia/lipid-disorders-in-children-screening-july-2016
      August 09, 2016 - Blood pressure was measured at baseline, year 1, year 3, and year 18. … Higher self-reported physical activity is associated with lower systolic blood pressure: the Dietary … Tracking of serum lipid levels, blood pressure, and body mass index from childhood to adulthood: the … Tracking of blood lipids and blood pressures in school age children: the Muscatine study. … Leading causes of death for age 12–19 y at baseline were unintentional or self-inflicted injury, circulatory

1392. “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.

1393. 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

1394. 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

1395. 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].

1396. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
      January 01, 2010 - 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 … Education in 2003 and that the long shifts medical interns worked led to 61 percent more needlestick injuries

1397. 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

1398. 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

1399. 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.

1400. 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.