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181. Social capital and knowledge sharing: effects on patient safety. | PSNet
     psnet.ahrq.gov/issue/social-capital-and-knowledge-sharing-effects-patient-safety
     September 15, 2011 - Related Resources From the Same Author(s) System approach to prevent common bile duct injury … September 15, 2011 Surgeon commitment to trauma care decreases missed injuries. … June 15, 2012 Interactive effects of nurse-experienced time pressure and burnout on patient … January 9, 2011 The culture of a trauma team in relation to human factors.

182. An innovative mobile approach for patient safety services: the case of a Taiwan health care provider. | PSNet
     psnet.ahrq.gov/issue/innovative-mobile-approach-patient-safety-services-case-taiwan-health-care-provider
     September 27, 2017 - Citation Related Resources From the Same Author(s) Surgeon commitment to trauma … care decreases missed injuries. … June 15, 2012 System approach to prevent common bile duct injury and enhance performance … August 30, 2023 Interactive effects of nurse-experienced time pressure and burnout on

183. Labor and Delivery Unit Safety: Shoulder Dystocia | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
     July 01, 2023 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management. … McRoberts maneuver used concurrently with suprapubic pressure [Call time] hh:mm:ss)  ___ : ___ : __ … Suprapubic pressure: Using a closed fist over pubic bone, push in an inward and downward motion. … This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated

184. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
     October 01, 2015 - MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse Events PSI (2013) OB Trauma … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. … Eliminating birth trauma at Ascencion Health.

185. Haste Makes Care Unsafe | PSNet
     psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
     January 07, 2015 - Benefits include measurement of important parameters (e.g., PA occlusion wedge pressure [an indirect … indication of left atrial pressure, a surrogate for left ventricular function], cardiac output, and mixed … hurry-up" situation should be a red flag that leads to recognition of the danger of such production pressures … While it is tempting to look at a case like this and focus only on understaffing or production pressures … Under all perioperative circumstances, but particularly with dangerously increased production pressure

186. Misconnection Leading to Arterial Thrombosis | PSNet
     psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
     January 29, 2021 - and procalcitonin levels were elevated, serum creatinine was 1.5 mg/dL (consistent with acute kidney injury … when the patient is hypotensive. 7,8,9 Arterial injection of drugs can cause ischemia by direct vessel injury … blood pressure.  … Display arterial and central venous pressures on the monitor Displaying the pressure measured at the … Injection injury of an aberrant superficial radial artery requiring surgical intervention.  

187. Puh-Electronic-Reports (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-electronic-reports.pdf
     February 10, 2014 - This report is helpful for nursing home staff and wound nurses to promote early identification of pressure … These details are available at the time the pressure ulcer is being assessed during wound rounds or … For example, the Pressure Ulcers At Risk for Delayed Healing Report; Weekly Wound Rounds Report; … DON or ADON, Nurse Manager, Wound Nurse, QI Director Root Cause Analysis for New Pressure Ulcers … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance

188. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
     December 01, 2012 - 9,257 6,892 Composite: ACSC Overall 17,570 24,934 20,620 17,662 23,518 18,337 Pressure … 10,435 7,884 Composite: ACSC Overall 19,406 27,524 22,656 19,821 25,958 20,278 Pressure … 5,382 4,110 Composite: ACSC Overall 12,450 16,541 14,919 11,150 15,491 12,897 Pressure … 3,777 3,248 Composite: ACSC Overall 5,094 6,963 6,484 4,695 6,310 5,297 Pressure … 8,215 6,780 Composite: ACSC Overall 17,579 23,121 20,378 17,055 21,295 18,297 Pressure

189. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
     April 02, 2025 - Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … - Injury to Neonate 0.0 0.1 0 $88,000 $ - N 2 3 9 Y Y Y Y Y PSI 18 Obstetric … Trauma-Vaginal Delivery With Instrument 134.8 135.1 17 $90,000 $ 1,530,000 N 2 3 8 Y Y … Y Y Y PSI 19 Obstetric Trauma-Vaginal Delivery Without Instrument 17.0 17.9 5 $96,000 $ … Rate 0.0 16.2 0 $117,815 $ - N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

190. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
     September 01, 2017 - Infected wound or decubitus. Jaundice. Rash. Fall-Related Injury. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes. … Wound or skin issues. Fall-related injury. Non-fall-related injury. Abnormal labs. … Fall/trauma. Anemia. Diabetes.

191. Disseminating and Implementing Patient-Centered Outcomes Research (PCOR) Evidence into Practice through Interoperable Clinical Decision Support (R18) | Digital Healthcare Research
     digital.ahrq.gov/funding-mechanism/disseminating-and-implementing-patient-centered-outcomes-research-pcor-evidence
     January 01, 2023 - Kawamoto, Kensaku Collaboration-Oriented Approach to Controlling High Blood Pressure … COACH) Description This research will refine an existing interoperable, patient-facing blood pressure … control tool--the Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) application … three diverse clinical settings; conduct a randomized trial to assess its impact on lowering blood pressure … decision support (CDS) tool for prevention of venous thromboembolism (VTE) to those with traumatic brain injury

192. On-Time Pressure Ulcer Healing: Introduction to Pressure Ulcer Healing Reports Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/erepguide.html
     December 01, 2016 - Pressure Ulcers at Risk for Delayed Healing. Weekly Wound Rounds Report. … home chains, and wound centers. … Injury Alliance. … The wound nurse, wound physician, and other disciplines attending wound rounds can see quickly which … If the pressure ulcer shows signs of delayed healing, as recorded on the wound assessment based on the

193. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

194. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

195. Chartbook on Hispanic Health Care: Slide Presentation—Part 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt2.html
     May 01, 2018 - Slide 39 Maternity Care for Hispanics Note: Trends: Birth trauma and obstetric trauma were … Slide 43 Birth trauma—injury to neonate per 1,000 live births, by race/ethnicity, 2004-2012 Image … : Graph shows birth trauma—injury to neonate per 1,000 live births: Year Total White Black … Note: Trends: Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 … Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic groups.

196. Documentation and Coding for the AHRQ Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
     March 15, 2016 - J Trauma 2007;63(5):1132-37. Iezzoni LI, Foley SM, Daley J, et al. 1992. … PDI 02 Pressure Ulcer Rate (stage III, IV, Unstageable) Diagnosis and site of pressure ulcer must … Document and code any associated pleural effusion or chest trauma. … Lack of Coding Specificity Measure Includes Only Elective Admissions PDI 11 Postoperative Wound … Dehiscence Rate X Depth of the wound dehiscence: external/superficial vs. internal/deep should

197. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
     psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
     September 25, 2024 - The required insufflation leads to an increase in peak inspiratory pressures, and this increase is more … pronounced during dilation as the balloon pressure increases tracheal stress. … Patient death or serious injury associated with intravascular air embolism that occurs while being cared … If endoscopy is utilized, decreased insufflation and lower dilation pressures may be necessary to avoid … Technical steps like using appropriate monitoring, minimizing insufflation and dilation pressures to

198. The Hidden Danger of Unseen Intravenous Catheters | PSNet
     psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
     October 04, 2023 - efflux of solutions from a vessel into the surrounding tissue during an infusion” and may cause grave injury … Outcomes and management of peripheral intravenous infiltration injuries. Hand (NY) . … Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. … June 2, 2015 Implementation of the World Health Organization Trauma Care Checklist Program … WebM&M Cases Intraosseous Line Extravasation in a Pediatric Trauma

199. The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet
     psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
     July 10, 2024 - September 27, 2016 Towards international consensus on patient harm: perspectives on pressure … injury policy. … August 7, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

200. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
     psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
     May 31, 2023 - High risk of errors, preventable death : Multidisciplinary trauma teams face tremendous time pressures … , and specialty situations (neurotrauma, burns, spinal cord injury, and orthopedic trauma). … For example, prompts might remind staff working with a patient with abnormally low blood pressure to … The program had a particularly large impact on the use of pressure dressings to control hemorrhage (p … Missed injuries in a level I trauma center. J Trauma. 2002 Apr;52(4):715-9.