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281. Inpatient fall prevention programs as a patient safety strategy: a systematic review. | PSNet
     psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
     May 26, 2016 - Considered a never event for hospitalized patients, falls that result in serious injury remain relatively … October 5, 2015 Preventing in-facility pressure ulcers as a patient safety strategy: … March 13, 2013 Venous thromboembolism after trauma: a never event?

282. Table 10: Outcome Indicators by Selected Home and Community-Based Services 1915(c) Waiver Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab10.html
     February 01, 2023 - Composite: ACSC Overall Yes 22,422 20,395 25,160 No 18,138 19,018 17,666 Pressure … 7,607 Composite: ACSC Overall 20,384 19,444 14,877 19,094 19,184 20,443 Pressure

283. The inevitability of physician burnout: implications for interventions. | PSNet
     psnet.ahrq.gov/issue/inevitability-physician-burnout-implications-interventions
     April 17, 2024 - September 18, 2024 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

284. Data Infographics | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/index.html
     February 01, 2025 - Antidepressant Prescriptions Potentially Preventable Pediatric Hospital Stays Most Common Cause of Injuries … 2017 People Who Spent the Most for Healthcare in 2017 Causes of Hospital Stays for Traumatic Brain Injury … in 2017 High Healthcare Spending in 2017 Sports-Related Traumatic Brain Injuries Among Children Inpatient … Anemia in Hemodialysis Patients Worse Among Blacks HRSA's Health Center Program Making Progress on Blood Pressure

285. Sleep and circadian misalignment for the hospitalist: a review. | PSNet
     psnet.ahrq.gov/issue/sleep-and-circadian-misalignment-hospitalist-review
     July 15, 2020 - May 14, 2018 Towards international consensus on patient harm: perspectives on pressure … injury policy.

286. Nurse well-being: a concept analysis. | PSNet
     psnet.ahrq.gov/issue/nurse-well-being-concept-analysis
     August 25, 2021 - March 16, 2022 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

287. Nurse burnout predicts self-reported medication administration errors in acute care hospitals. | PSNet
     psnet.ahrq.gov/issue/nurse-burnout-predicts-self-reported-medication-administration-errors-acute-care-hospitals
     August 25, 2021 - August 25, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

288. TeamSTEPPS Core Curriculum. | PSNet
     psnet.ahrq.gov/issue/teamstepps-core-curriculum
     August 01, 2012 - July 12, 2018 Pressure Injury Prevention in Hospitals Training Program.

289. Table 9: Outcome Indicators by Selected Home and Community-Based Services Medicaid State Plan Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab9.html
     February 01, 2023 - Overall Yes 18,922 20,115 18,052 19,228 No 28,131 18,583 22,752 19,363 Pressure … Composite: ACSC Overall 19,083 19,110 16,427 19,636 23,560 27,103 21,664 20,810 Pressure

290. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis | PSNet
     psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
     October 28, 2020 - antibiotics with some initial improvement in his symptoms and blood pressure. … Laboratory test results revealed a mildly elevated white count, acute kidney injury, and elevated liver … The patient's blood pressure continued to trend downward to 60/40 mm Hg. … elevated white blood cell count) and end-organ dysfunction (elevated liver function tests, acute kidney injury … Sight August 1, 2009 WebM&M Cases Missing Trauma

291. Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. | PSNet
     psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
     August 14, 2024 - The cause of death was documented as hip trauma from the fall at the nursing home. … , 1 such as fractures or head trauma, falls can have important psychological impacts on individuals … Likewise, her blood pressure recordings, lying, sitting or standing, were not noted so we don’t know … to risk reduction for this resident might have been to evaluate and monitor lying and standing blood pressures … Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older

292. Crossing the Line | PSNet
     psnet.ahrq.gov/web-mm/crossing-line
     December 01, 2012 - catheterization at the internal jugular site, similar to the ones seen in this case, suggest arterial injury … The timing of this patient's neurologic deterioration favors an arterial injury. … The key to preventing serious injury to the artery is identifying the arterial puncture prior to dilating … The most definitive technique is to attach a pressure transducer to the needle and inspect the waveform … April 15, 2009 A randomized trial of a multifactorial strategy to prevent serious fall injuries

293. Slide 1 (pdf file)
     hcup-us.ahrq.gov/datainnovations/ICD10Imp_Romano_NAHDO_October2016.pdf
     October 27, 2016 - body part (see also “restriction”) 6 Example QIs with mapping challenges • PSI 14, Postoperative wound … 54.61, Reclosure of postoperative disruption of abdominal wall • PSI 10, Postoperative acute kidney injury … Internal Medicine, Neonatal/Pediatric, Neurology, Obstetrics and gynecology, Orthopedics, General and trauma … or Spinal Fusion • AHA Coding Clinic, 4Q 2013, 30(4):116 – “Spinal decompression is the removal of pressure … from the spinal cord… if a laminectomy is performed to remove pressure from the spinal cord, assign

294. Appendix B. Detailed Research Domain Framework Definitions and Classification Rules | Agency for Healthcare Research and Quality
     www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-b.html
     June 01, 2020 - Examples of intermediate outcomes include clinical health measures (e.g., adequate control of blood pressure … Intermediate outcomes include measures related to the incidence of chronic conditions—such as high blood pressure … This category includes studies of population health, injury occurrence, and disease progression. … Examples of intermediate outcomes of care are blood pressure, asthma, and glycemic control.  … that primarily examine how to treat injuries or disease (even if the injury or disease is preventable

295. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
     September 01, 2014 - With Central Venous Catheters Falls MPSMS In-Hospital Patient Falls Obstetric Adverse Events PSI OB Trauma … Pressure Ulcers Surgical Site Infections NHSN SSIs combined for 17 procedures based on CDC NHSN data … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury, and the national … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated Pneumonia … Falls MPSMS In-Hospital Patient Falls 262,317 32,750,000 8.010 Obstetric Adverse Events PSI OB Trauma

296. Clinical Decision Support for Mild Traumatic Brain Injury - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/k08hs021271-melnick-final-report-2018.pdf
     January 01, 2018 - However, other ED‐spec ific factors also contribute to overuse, such as time and volume pressures, a … Participants were patients and clinicians recruited from an urban, academic Level I trauma center ED … Subjects were recruited from patients treated and released with minor head injuries and providers in … Field Testing To optimize naturalistic decision making under the constraints of the complex, high-pressure … clinician’s decision and patient engagement and education around patient-specific risk about head injuries

297. Table 11: Outcome Indicators by Use of Selected Home and Community-Based Services Medicaid State Plan Services, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab11.html
     February 01, 2023 - Overall Yes 14,177 28,212 18,788 9,372 No 19,380 19,211 19,521 20,716 Pressure … Composite: ACSC Overall 50,783 40,549 9,972 20,001 18,997 10,923 20,108 19,218 Pressure

298. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls | PSNet
     psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
     December 18, 2024 - no injury. … injury to that person and their psyche. … I was a site Principal Investigator (PI) for the Strategies to Reduce Injuries and Develop Confidence … In hospitals, falls with injuries can lead to other adverse outcomes including pressure injuries or … One study found that providing patients at risk for falls with Smart Socks , which contain pressure

299. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4e_combo_psi08-postophipfx-bestpractices.pdf
     May 20, 2016 - In 2008 the Centers for Medicaid & Medicare Services (CMS) identified falls and trauma—including fractures—as … Prevention Protocol Use a standardized fall prevention protocol to help reduce falls and associated injury … /fallspx/fallspxmanual.pdf http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Transforming care at the bedside how-to guide: reducing patient injuries from falls.http://www.ihi.org … High blood pressure and bone-mineral loss in elderly white women: a prospective study.

300. Communication: Severe Hypertension (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
     July 01, 2023 - patient's family members. 4 Hospital AIM Team Leads SPPC‐II Maternal and Perinatal Deaths and Injuries … communication breakdowns are identified as the primary root cause of maternal and perinatal deaths and injuries … Other root causes for maternal and perinatal deaths and injuries are— • Assessment (i.e., the adequacy … Severe‐range blood pressure was sustained for nearly an hour. Ms. … Untitled Communication Severe Hypertension Communication is… Maternal and Perinatal Deaths and Injuries