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281. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
     psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
     March 09, 2022 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic pressures, 52–54 some … Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model. … Quantification of leakage pressures after durotomy repairs in the canine. … January 23, 2019 Classifying errors in preventable and potentially preventable trauma

282. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866343/psn-pdf
     December 31, 2024 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … patients first present to the ED.1 The presence of pulmonary edema with hypoxemia and acute kidney injury … with an especially elevated diastolic pressure. … nitroglycerin (given that nitroprusside is relatively contraindicated in the setting of acute kidney injury … treating hypertensive emergencies, choosing appropriate antihypertensives for patients with end-organ injury

283. C1 Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
     June 02, 2025 - purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … Rate on scale of 10 (agree/high) to 0 (disagree/low) PSI 14 Postoperative Wound … Dehiscence PSI 15 Accidental Puncture or Laceration PSI 17 Birth Trauma- Injury to Neonate PSI … 18 Obstetric Trauma- Vaginal Delivery With Instrument PSI 19 Obstetric Trauma- Vaginal Delivery … 09 Postoperative Respiratory Failure Rate PDI 10 Postoperative Sepsis Rate PDI 11 Postoperative Wound

284. Archived: Final Research Plan: Preeclampsia: Screening | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan109/preeclampsia-screening-april-2017
     August 14, 2014 - How effectively do screening tests (e.g., blood pressure, proteinuria) identify women with preeclampsia … Preeclampsia risk assessment and screening KQs 1, 4, 5: Screening tests for preeclampsia (e.g., blood pressure … information obtained from patient history or measurements routinely collected in primary care (e.g., blood pressure … health outcomes (KQ 1): Maternal mortality and serious morbidity (e.g., organ or system failure or injury … neonatal mortality and serious morbidity (e.g., intrauterine growth restriction, low birthweight, brain injury

285. Statistical Brief #130: Emergency Department Visits and Inpatient Hospital Stays for All-Terrain-Vehicle-Related Injuries, 2009 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb130.pdf
     March 01, 2012 - Introduction All-terrain vehicles (ATVs) are small open motorized vehicles designed with large low-pressure … Annual Report of ATV-Related Deaths and Injuries. … Journal of Trauma-Injury Infection and Critical Care 69(6): 1344–1349. 5 Aitken, M. E., C. J. … ED visits for ATV injuries were more likely to occur on a weekend than the total of other injury-related … Compared with all injury related visits, those for ATV injuries were more likely to be covered by private

286. Don’t Bite Your Tongue. | PSNet
     psnet.ahrq.gov/web-mm/dont-bite-your-tongue
     September 18, 2024 - Changes in motor evoked potentials can indicate an impending neurologic injury and should trigger an … Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years.  … Airway injury during anesthesia: a closed claims analysis.  … Cost analysis of intubation-related tracheal injury using a national database.  … August 1, 2010 WebM&M Cases Under Pressure: Delayed

287. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41985/psn-pdf
     October 26, 2016 - The most common adverse events reported were pressure ulcers and fall- related injuries or deaths. … serious-reportable-events-healthcare-2011-update https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities … https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities

288. Summary of USPSTF Final Recommendation: Interventions to Prevent Falls in Community-Dwelling Older Adults (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/Xm5_jgUrXXGAJe8WJh_9KK
     June 01, 2024 - initial assessment of modifiable risk factors for falls (eg, balance, gait, vision, postural blood pressure … Falls are the leading cause of injury-related morbidity and mortality among older adults in the US. … adults 65 years or older reported at least 1 fall in the past year and 10.2% reported a fall- related injury … In 2021, 38,742 deaths resulted from fall-related injuries. … • The CDC’s STEADI (Stopping Elderly Accidents, Death, and Injuries) initiative helps reduce fall

289. Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. | PSNet
     psnet.ahrq.gov/issue/estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-medical-and-surgical
     July 11, 2018 - Some adverse events are sensitive to aspects of nursing care , including pressure injuries , falls, … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure

290. Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. | PSNet
     psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
     November 01, 2017 - The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates … August 10, 2022 Complexity bias in the prevention of iatrogenic injury: why specific … May 13, 2020 Assessment of nursing home reporting of major injury falls for quality measurement

291. Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Technical Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0206-technicalspecs.pdf
     May 01, 2016 - Exclusions • Denominator/Numerator Exclusions o Trauma-related headache or pain (Table … IMG3) on the day of or within 7 days prior to imaging o Head trauma or suspected abuse/neglect (Table … 339.43 Other complicated 339.44 OTHER Post- traumatic headache 339.2x Acute pain due to trauma … excision of foreign body from brain 61570 Craniectomy or craniotomy; with treatment of penetrating wound … 852.x Other/unspecified intracranial hemorrhage following injury 853.x Intracranial injury of other

292. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
     December 01, 2017 - Few days later, he develops fever and his blood pressure drops. … Keeps patients from having to get up to urinate, protecting them from injury. … Trauma) Admitting service (e.g. … Is the patient incontinent with open sacral or perineal wounds? … Protocolized care for trauma Incontinence without open sacral or perineal wounds Pre-operative

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867429/psn-pdf
     December 18, 2024 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic pressures,52–54 some … Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model … Quantification of leakage pressures after durotomy repairs in the canine. … Occult spinal pseudomeningocele following a trivial injury successfully treated with a lumboperitoneal

294. Appendix B11: Fall Interventions Plan | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6.html
     February 01, 2023 - Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions __ Low blood pressure … __ Behavior management strategies __ Increase assistance and surveillance    __ Position or pressure … _ Increase activities involvement    __ Other ___________________________ __ Reduce risk of injury

295. Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
     January 01, 2021 - Patient outcome variables Patient falls and injury falls • Patient falls/1,000 patient days. … • Injury falls/1,000 patient days. … • Percent of patients with suspected deep tissue injury. 3 Table 1. … • Percent of patients with hospital-acquired suspected deep tissue injury. … ulcers stages III and IV, as well as fall and injury fall incidence and rates.

296. Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care (pdf file)
     www.ahrq.gov/downloads/pub/advances2/vol1/advances-hook_25.pdf
     February 26, 2008 - , impaired physical mobility, accidental injuries, patient safety, safety management, injury control … Minor: Resulted in application of a dressing, ice, cleaning of a wound, limb elevation, or topical … Blood pressure changes on upright tilting predict falls in older people. … Complications of preinjury warfarin use in the trauma patient. J Trauma 2003; 54: 842-847. 36. … Minor head trauma in anticoagulated patients. Acad Emerg Med 1999; 6: 121-124. 38.

297. Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Hook_25.pdf
     February 26, 2008 - , impaired physical mobility, accidental injuries, patient safety, safety management, injury control … Minor: Resulted in application of a dressing, ice, cleaning of a wound, limb elevation, or topical … Blood pressure changes on upright tilting predict falls in older people. … Complications of preinjury warfarin use in the trauma patient. J Trauma 2003; 54: 842-847. 36. … Minor head trauma in anticoagulated patients. Acad Emerg Med 1999; 6: 121-124. 38.

298. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013-refs.html
     October 01, 2015 - Injury From Falls Barrett JA, Bradshaw M, Hutchinson K, et al. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers Agency for Healthcare Research and Quality.

299. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ref.html
     December 01, 2014 - Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers Agency for Healthcare Research and Quality. … Eliminating facility-acquired pressure ulcers at Ascension Health .

300. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet
     psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
     May 01, 2018 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … patients first present to the ED. 1 The presence of pulmonary edema with hypoxemia and acute kidney injury … with an especially elevated diastolic pressure. … nitroglycerin (given that nitroprusside is relatively contraindicated in the setting of acute kidney injury … treating hypertensive emergencies, choosing appropriate antihypertensives for patients with end-organ injury