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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Mohr.pdf
February 01, 2004 - Because of the age of
pediatric patients, when an error leads to injury it may have an impact on the … No complete loss of consciousness -- mom caught
him with no head injury sustained. … post-term newborn infant with mild respiratory
distress syndrome requiring continuous positive airway pressure … The occurrence of an error did not imply harm or injury to the patient.
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pdf/epc-year-in-review-2021.pdf
January 01, 2021 - Health of Wheelchair
Users: A Systematic Review in Multiple Sclerosis,
Cerebral Palsy, and Spinal Cord Injury … Health of Wheelchair Users: A Systematic Review in Multiple Sclerosis,
Cerebral Palsy, and Spinal Cord Injury … health of wheelchair users: a
systematic review in multiple sclerosis, cerebral palsy, and spinal cord injury … Postpartum Home Blood Pressure Monitoring, Postpartum Treatment of Hypertensive Disorders of
Pregnancy
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hcup-us.ahrq.gov/reports/statbriefs/sb77.pdf
July 01, 2009 - by law1
to receive a medical screening exam to determine if they need
treatment for an illness or injury … who is paying for ED care, what the charges
are for the care, and how to potentially relieve this pressure
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Due to the delayed diagnosis, the patient suffered permanent brain injury requiring around-the-clock … These barriers include professional hierarchy, time pressure, challenging workloads, and inadequate structures
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - sentinel events—defined as "an unexpected occurrence involving death or serious physical or psychological injury … Post-Tracheostomy Care
May 29, 2024
WebM&M Cases
Under Pressure
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - harmed by having the incorrect catheter placed, but the error
was eventually discovered and further injury … The efficacy of self-
check is limited by time pressure and by asymmetric knowledge—individuals in the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-engaging-clinicians-051413.ppt
January 01, 2013 - Reduce antibiotic use
Reduce potential of increased resistance and Clostridium difficile disease Reduce trauma … (mechanical complications):
Metal and urethral injury
Hematuria
Hospitalists Geriatricians
Infectious … Inappropriate urinary catheter use may negatively affect the surgeon’s profile
Risk of infection and trauma … They may lead to urinary tract infections and cause mechanical trauma to the urethra and bladder. … They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/recombinant-factor-viia_disposition-comments.pdf
June 01, 2010 - the wound patterns in the two settings
are vastly different. … injury and hypotension, and these conditions are thought to
drive the coagulopathy of trauma. … Therefore, despite the
differences in injury mechanisms, injuries of sufficient severity … trumps that of
other injuries and where the other injuries are not of a life-threatening
hemorrhagic … guideline from the American Heart
Association/American Stroke Association Stroke Council, High
Blood Pressure
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/disabilities-quality-improvement-outcomes_executive.pdf
October 01, 2012 - Patients include those with temporary
disability due to trauma or illness and those with “stable”
disabling … categories
of disability etiology/timing of onset are: congenital/
developmental, acquired (disease or trauma … including:
8
• Preventive dental care
• Preventive medical care
• Urinary tract infections
• Pressure … Aging with spinal cord
injury. Phys Med Rehab Clin N Am. 2010 May;21(2):
383-402. … Brain
Injury. 2011;25(1):83-100.
36. Petry K, Maes B, Vlaskamp C.
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - The following morning, the patient's condition improved with normalization of blood pressure, improved … Evaluation of an emergency radiology quality assurance program at a level I trauma center: abdominal … Head trauma: CT scan interpretation by radiology residents versus staff radiologists. … Around-the-clock attending radiology coverage is essential to avoid mistakes in the care of trauma patients … May 1, 2011
Delayed or missed diagnosis of cervical spine injuries.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/health-literacy_research-protocol.pdf
January 22, 2010 - Health literacy, morbidity, and quality of life among
individuals with spinal cord injury. … Discharge knowledge and concerns of patients
going home with a wound. … J Wound Ostomy Continence Nurs 2007;34:245-53. … Literacy and blood pressure—do healthcare systems
influence this relationship? … Comprehension of discharge information for minor head injury: a randomised
controlled trial in New Zealand
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case2.html
November 01, 2014 - Participation is required in the following priority areas: falls and fall injuries, pressure ulcers, … For example, in 2008 the national system launched a campaign to have zero preventable injuries or deaths … , the department was working toward certification as an American College of Surgeons (ACS) Level II Trauma … The ED successfully launched a trauma center and identified a new director in early 2010. … Staff perceived a shift of work to other staff because of the pressures of Lean process.
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - Dental care providers are advised to:
If possible, perform procedures in a negative pressure room, ( … least 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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
March 09, 2005 - Activities
Falls* Nutritional status
Dehydration Dental care
Feeding tubes† Physical restraints†
Pressure … Factors associated with serious injury
during falls by ambulatory nursing home residents. … Fall injuries in the elderly. Clin
Geriatr Med 1985;1(3):501–12.
28. Monane M, Avorn J.
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - depression, of which 77% resulted in severe brain damage or death. 13 Most of these opioid-related injuries … oximetry (SpO 2 ) to monitor patient oxygenation and ventilation. 31 Capnography measures the partial pressure … Opioid PC A
Monitoring Component
Assessment Types
Vital Signs
Heart Rate
Blood Pressure
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt3.html
May 01, 2018 - Slide 10
Adults who needed care right away for an illness, injury, or condition in the last 12 months … ) among Hispanics, 2002-2012
Image: Graphs show adults who needed care right away for an illness, injury … Slide 11
Children who needed care right away for an illness, injury, or condition in the last 12 … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … Importance: Many patients who receive home health care are recovering from an injury or illness and
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE-rev.pdf
January 01, 2023 - 1,000 elective-surgery admissions, age
18 and over
HCUP 2020
Reclosure of postoperative abdominal wound … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma … stages 2-4
pressure ulcer or unstageable pressure ulcer
MDS 2021
Low-risk, long-stay nursing home … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma … stages 2-4
pressure ulcer or unstageable pressure ulcer
MDS 2021
Low-risk, long-stay nursing home
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023-NHQDR-appendixes-ACDE.pdf
January 01, 2023 - 1,000 elective-surgery admissions, age
18 and over
HCUP 2020
Reclosure of postoperative abdominal wound … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma … stages 2-4
pressure ulcer or unstageable pressure ulcer
MDS 2021
Low-risk, long-stay nursing home … 2020
Home health care patients whose management of oral
medications improved
OASIS 2021
Birth trauma … stages 2-4
pressure ulcer or unstageable pressure ulcer
MDS 2021
Low-risk, long-stay nursing home
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-appendix-combined.pdf
October 25, 2022 - HCUP 2019
Home health care patients whose management of oral medications
improved OASIS 2020
Birth trauma … pressure ulcer MDS 2019
Low-risk, long-stay nursing home residents with a catheter inserted
and left … MDS 2019
Short-stay nursing home patients with pressure ulcers that are new
or worsened MDS 2018 … HCUP 2019
Home health care patients whose management of oral medications
improved OASIS 2020
Birth trauma … MDS 2019
Short-stay nursing home patients with pressure ulcers that are new or
worsened MDS 2018
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - 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