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361. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - event type; and, detailed information about specific event types, such as the distribution of various injuries … pertaining to nine patient safety event types that represent the majority of reported preventable injuries … Event-Specific Formats pertain to nine patient safety events that represent the great majority of preventable injuries … that they represent minor injuries such as soreness, bumps, and minor abrasions. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

362. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
     October 27, 2014 - MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse Events PSI (2012) 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.

363. Appendix C. Case Study and Program Examples | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
     December 01, 2017 - She was assessed to have no injuries resulting from the fall. … Physical restraint—increases risk of serious injury. … Full side rails—increase risk of serious injury. … . ___ provide frequent reminders about call bell. ___ conduct trial use of a change in position/pressure … Use of pressure, position alarm. Use of hip protectors. No physical restraint use.

364. Statistical Brief #130
     hcup-us.ahrq.gov/reports/statbriefs/sb130.jsp
     May 01, 2012 - Introduction All-terrain vehicles (ATVs) are small open motorized vehicles designed with large low-pressure … 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 … Case definition The External Cause of Injury codes (E-codes) used to define ATV-related injuries were … Journal of Trauma-Injury Infection and Critical Care 69(6): 1344-1349. 5 Aitken, M. E., C. J.

365. 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

366. Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. | PSNet
     psnet.ahrq.gov/issue/barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-meta-synthesis
     August 25, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

367. Declines in Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
     June 02, 2025 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse Events Pressure

368. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
     January 01, 2010 - Smith (2) Because of his immobility, he develops a pressure ulcer on his sacrum. … Few days later, he develops fever and his blood pressure drops. … Incontinent with open sacral/perineal wounds Consult with wound care End of life/hospice Be sure it … Trauma) Admitting service (e.g. … Protocolized care for trauma Incontinence without open sacral or perineal wounds Pre-operative

369. The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/impact-dedicated-medication-nurses-medication-administration-error-rate-randomized-controlled
     September 24, 2010 - July 17, 2024 Early identification and evaluation of severe pressure injuries. … March 19, 2019 Detection of missed injuries in a pediatric trauma center with the addition

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49485/psn-pdf
     August 29, 2024 - The surgery was uncomplicated—her blood pressures intraoperatively were within 20% of her baseline, … CRAO caused by globe compression is usually associated with periorbital trauma (e.g., bruising, proptosis … with other signs of periorbital trauma. … Eye injuries after nonocular surgery. A study of 60,965 anesthetics from 1988 to 1992. … Injuries to the visual system and other sense organs. In: Benumof J, Saidman L, eds.

371. On-Time Preventable Hospital and ED Visits Functional Specs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
     August 01, 2017 - Ulcer Vendor determined or Wound Assessment Pressure ulcer Stage II, III, IV, or unstageable. … IF wound assessment date ≤7 days of report date AND at least one pressure ulcer with ulcer stage = … then display X in Wound • Infected wound or decubitus ulcer • Jaundice • Rash 10 Injury: Fall … X in Injury: 11 Injury: Non- Fall Related Transfer Note • • Major injury Minor injury IF …  Chest pain/angina  Dizzy/lightheaded Non-Fall-Related Injury  Major injury  Minor injury

372. worker-health-protocol-150526 (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/worker-health_research-protocol.pdf
     May 26, 2015 - Intermediate outcomes (e.g., change in blood pressure, tobacco use, or hazardous exposures) c. … [Mesh] OR “worksite health” AND ((“Health Promotion”[Mesh]) OR “Accident Prevention”[Mesh]) OR “Wounds … and Injuries/prevention and control”[Mesh Humans English language Publication date 1990 to [date … Occupational injury and illness in the United States. … Employer-Reported Workplace Injury and Illness Summary.

373. Technical rationality and the decentring of patients and care delivery: a critique of 'unavoidable' in the context of patient harm. | PSNet
     psnet.ahrq.gov/issue/technical-rationality-and-decentring-patients-and-care-delivery-critique-unavoidable-context
     October 08, 2016 - From the Same Author(s) Towards international consensus on patient harm: perspectives on pressure … injury policy. … June 14, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

374. Intentional rounding—an integrative literature review. | PSNet
     psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review
     October 08, 2016 - The authors explore areas of impact, including patient satisfaction, falls , and hospital-acquired pressure … From the Same Author(s) Towards international consensus on patient harm: perspectives on pressure … injury policy.

375. The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England. | PSNet
     psnet.ahrq.gov/issue/effect-providing-staff-training-and-enhanced-support-care-homes-care-processes-safety-climate
     September 15, 2021 - Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in … After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced. … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … See More About The Topic Long-Term Care Quality and Safety Professionals Geriatrics Pressure

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49636/psn-pdf
     October 01, 2011 - year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease was admitted to a trauma … service after injuries suffered from an assault and battery. … The patient's injuries included a left shoulder dislocation and a minimally displaced fracture of a … After reviewing the medical records, the PT noted the initial shoulder injury on admission. … In addition to providing a general assessment, the PT expressed concern that the shoulder injury had

377. Complications of ECMO During Transport | PSNet
     psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
     January 27, 2021 - The most common complications of ECMO are bleeding from cannulation sites (15-20%) or surgical wounds … Brain injury during venovenous extracorporeal membrane oxygenation. … Pressures – does the pump produce a pressure adequate for flow? What are the pressure trends? … Pressures are monitored before (pre-pump pressure), between pump and oxygenator (pre-oxygenator), and … January 11, 2017 Evaluation of wound photography for remote postoperative assessment

378. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … captures the specific type of physical injury sustained in the fall as TYPE OF INJURY AS RESULT OF … that they represent minor injuries such as soreness, bumps, and minor abrasions. … and the type of the injury. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

379. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
     May 01, 2017 - 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) ____:____:____ … The ideal approach is for the clinician to put pressure in the antecubital fossa of the posterior arm … This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49697/psn-pdf
     December 01, 2013 - are difficult to compare, current estimates put medication error rates at 1 in 100 anesthetics.(2) Injury … from such errors are estimated to occur with 1% of errors.(3) By extrapolation, then, the risk of injury … American Society of Anesthesiologists Closed Claims Project recently presented an update on patient injuries … Medication error etiology is multifactorial and includes a distracting environment and production pressure … Patient injuries from anesthesia gas delivery equipment: a closed claims update.