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321. 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/ereport-slides.html
     September 01, 2017 - showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure … DNR,DNH, MOLST, or POLST Order in Place Oxygen Therapy Catheter or Ostomy Present Stage II or > Pressure … Gastrointestinal/ Genitourinary Symptoms Endocrine/ Metabolic/ Nutrition Issues Wound … Genitourinary Endocrine/ Nutritional/ Metabolic Musculoskeletal/ Joint Symptoms Wound … Circulatory Problems Hypertension or Renal Failure Gastroenteritis Angina Pectoris Falls /Trauma

322. The Top Five: A Review of Post-Pandemic Patient Safety Priorities. | PSNet
     psnet.ahrq.gov/issue/top-five-review-post-pandemic-patient-safety-priorities
     July 10, 2024 - demands during the crisis to affect falls, medication safety, healthcare associated infections , and pressure … injuries.

323. How can interventions more directly address drivers of unprofessional behaviour between healthcare staff? | PSNet
     psnet.ahrq.gov/issue/how-can-interventions-more-directly-address-drivers-unprofessional-behaviour-between
     October 09, 2024 - December 19, 2018 Association of hospital participation in a regional trauma quality … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

324. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. | PSNet
     psnet.ahrq.gov/issue/adverse-events-rehabilitation-hospitals-national-incidence-among-medicare-beneficiaries
     January 09, 2019 - provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury … Nearly half of the events were considered preventable, with the most common types of events including pressure

325. Archived: Final Evidence Summary: Obesity in Adults: Screening and Management | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary38/obesity-in-adults-screening-and-management-2012
     October 15, 2011 - Limited data suggested no increased risk for serious injuries or eating disorders. … Safety of strength training in premenopausal women: musculoskeletal injuries from a two-year randomized … Questions and answers: orlistat and severe liver injury. FDA Drug Bulletin. May 26, 2010. … Orlistat and acute kidney injury: an analysis of 953 patients [Letter]. … found that orlistat recipients required more vitamin supplementation during the study - Liver injury

326. Breakage of a PICC Line | PSNet
     psnet.ahrq.gov/web-mm/breakage-picc-line
     June 21, 2023 - These include injury to vessels or organs during insertion, catheter migration or malposition with extravasation … The study found that the most common complications were wound oozing, phlebitis, occlusion, infection … It seems prudent to avoid flushing catheters under high pressure or using small syringes. … PICC complications include injury to other vessels or organs during insertion, catheter migration or … Caregivers should be warned against flushing PICCs with small-volume syringes or with too much pressure

327. Communication: Severe Hypertension - PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
     July 01, 2023 - interruption to a doctor who is with a patient's family members. 2 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, … Smith so you can treat her severe blood pressure and draw labs.  … Smith, you do not have severe-range blood pressure at this time. 

328. Methods Applying AHRQ Quality Indicators to Healthcare Cost and Utilization Project (HCUP) Data for the Tenth (2012) NHQR and NHDR (pdf file)
     hcup-us.ahrq.gov/reports/methods/2012-02.pdf
     January 01, 2012 - E Codes: Another issue relates to external cause-of-injury reporting. … data to help identify complications of care or to exclude cases (e.g., poisonings, self-inflicted injury … , delirium and other psychoses, anoxic brain injury; patients with metastatic cancer, lymphoid malignancy … , bone malignancy, and self-inflicted injury; admissions for diseases and disorders of the musculoskeletal … PSI 17 Birth trauma - injury to neonate per 1,000 live births (excluding preterm and osteogenesis imperfecta

329. Nursing and Patient Safety | PSNet
     psnet.ahrq.gov/primer/nursing-and-patient-safety
     September 15, 2024 - However, the key findings in a recent integrative review include fewer pressure ulcers and urinary tract … job dissatisfaction and absenteeism for nurses, as well as to medication errors, infections, falls, pressure … injuries, readmissions, and failure to rescue . 10 In addition, If bullying is present within the … and unit culture promote teamwork and lead to nursing job satisfaction that is likely to reduce the pressures … injuries.

330. Chapter 4. Long Term Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man4.html
     December 01, 2017 - If there is a drop of 20 mm Hg or more in the resident's systolic pressure 1 minute after standing, the … Use of pressure, position, seat belt or other alarm. … Room sensors to detect resident movement; position or pressure alarms on the bed, chair or wheelchair … Trying to climb over bedrails may well result in a serious fall related injury. … For residents who are in danger of head injury, a helmet can provide protection.

331. Poaaddonfile042208Ahrqmod (pdf file)
     hcup-us.ahrq.gov/datainnovations/clinicaldata/POAAddonfile042208AHRQMod.pdf
     September 23, 2010 - their successors, omit decimal include POA value as required as 8th character. 26 External Cause of Injury … their successors, omit decimal include POA value as required as 8th character. 27 External Cause of Injury … their successors, omit decimal include POA value as required as 8th character. 28 External Cause of Injury … unspecified Urinary Tract Infection 3 Digit DX code 4 Digit DX code Decubitus Ulcer on Heel- Bedsore or Pressure

332. Chapter 2. Fall Response | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
     December 01, 2017 - the nurse after a resident falls should include a review of the resident systems and description of injuries … Postural blood pressure and apical heart rate. Finger stick glucose (for diabetics). … The presence or absence of a resultant injury is not a factor in the definition of a fall. … A fall without injury is still a fall.

333. Case Scenarios: Handling Challenging Communications | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
     August 01, 2022 - Eventually the team is able to re-establish Mary's normal heart rate, blood pressure, and adequate blood … During the resuscitation efforts, information obtained from the devices monitoring Mary's EKG, blood pressure … Over the next few days, it is clear that he has suffered a significant brain injury due to the lack of

334. The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. | PSNet
     psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
     October 09, 2024 - Are evidence-based practices associated with effective prevention of hospital-acquired pressure … December 21, 2017 Complexity bias in the prevention of iatrogenic injury: why specific

335. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-ref.html
     May 01, 2023 - Costs of venous thromboembolism, catheter-associated urinary tract infection, and pressure ulcer. … The costs of medical falls by component of cost, timing, and injury severity. … Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization … Ostomy Wound Manage . 2016 Nov;62(11):30-8. 65. Mendizabal A, Thibault DP, Willis AW. … Marginal hospital cost of surgery-related hospital-acquired pressure ulcers.

336. Hierarchy and medical error: speaking up when witnessing an error. | PSNet
     psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
     April 14, 2011 - July 19, 2023 Towards international consensus on patient harm: perspectives on pressure … injury policy.

337. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33589/psn-pdf
     September 15, 2024 - reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures … A classic example is that of the military aircraft carrier: despite significant production pressures … A regional health system in Canada reported a decrease in adverse events such as falls, pressure injuries

338. The nurse's experience of decision-making processes in missed nursing care: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/nurses-experience-decision-making-processes-missed-nursing-care-qualitative-study
     May 11, 2022 - May 19, 2021 Surgeon commitment to trauma care decreases missed injuries. … September 27, 2017 Organisational strategies to implement hospital pressure ulcer prevention

339. Hypoxemia after Emergency Intubation | PSNet
     psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
     March 24, 2019 - The patient arrived at the ED with seizures, tachypneic with a respiratory rate of 30, blood pressure … significant reduction in the number of unrecognized esophageal intubations and cases of hypoxic brain injury … P stands for pneumothorax, which typically occurs in trauma patients with rib fractures or patients … J Trauma Inj . 2019;32(3):136-142. [ Free full text ] Xuan Q, Lyu Z, Chen Q, et al. … Continuous positive airway pressure versus high-flow nasal cannula oxygen therapy for acute hypoxemic

340. AHRQ Stats | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/ahrq-stats.html
     January 01, 2025 - , by Cause of Injury, 2017 .) … Trauma During Childbirth The rate of obstetric trauma during childbirth involving instruments such as … Decreasing Pressure Ulcers Among Hospital Patients The average rate of hospital-associated pressure ulcers … Pressure Ulcer Rates of Hospital Patients About 1.2 million cases of hospital-acquired pressure ulcers … highest average expenses per person were for the treatment of heart conditions ($3,794 per person), trauma-related