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381. Title: IMProving Outcomes Related to Patients Through Advanced Nursing Technology (IMPORTANT) (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r03hs027006-sun-final-report-2023.pdf
     January 01, 2023 - enhancing nurse surveillance and its effects on associated nurse-sensitive patient outcomes—falls, pressure … ulcer injury.11 For example, nurses play a critical role in infection prevention both in … Ulcer Injuries •Hospital Aquired Infections Design. … ulcer injuries, and patient falls. … A hospital system approach at decreasing falls with injuries and cost.

382. Chapter 4 | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/resources/vision/resources/vision4.html
     October 01, 2002 - a limitation in life activities may stem from one or more of genetic conditions, acquired diseases, traumas … health care and health information, and have more exposure to interpersonal violence and intentional injury … therapies. 104 The study included 85 patients with various nervous, circulatory, musculoskeletal, and injury … and other care for people with disabilities is of increasing concern given ongoing cost-containment pressures

383. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet
     psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
     January 29, 2021 - The patient did not suffer permanent neurological injury from the prolonged hypoxemia, but she did require … Health care providers are frequently under time pressure to bring the next patient to the operating room … Production pressure, medical errors, and the pre-anesthesia checkout. … Production pressures among anaesthesiologists in Singapore. … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

384. Optimizing medication safety in the home. | PSNet
     psnet.ahrq.gov/issue/optimizing-medication-safety-home
     August 24, 2015 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

385. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet
     psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
     March 18, 2020 - Anesthetic factors such as difficult intubation , light anesthesia, prolonged surgery duration, or positive pressure … contents in the mouth or airway, other signs of aspiration include persistent hypoxia, high airway pressures … Positive pressure mask ventilation for an aspirating patient is not ideal due to the risk of pushing … July 31, 2024 WebM&M Cases Uterine Artery Injury … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

386. Grand Rounds Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
     August 01, 2022 - Say: Today's Presentation Goals are to: Highlight the gap between optimal response to medical injury … The nursing staff in the room had Michelle connected to a monitor and monitored her heart rate, blood pressure … Slide 12 Say: The response to medical injury involves more than just what to do and what … field of ergonomics; as we work more at desks and computers, these areas are redesigned to help prevent injuries … Slide 35 Say: In addition to the organization Medically Induced Trauma Support Services

387. Unexplained Apnea Under Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
     December 01, 2005 - disabling adverse events, 45% of those events were caused by errors.( 6 ) In a large insurer’s study, injuries … Poor system design also makes errors difficult to intercept before injury occurs. … muscle weakness, and visual disturbances Extreme or unexpected increase or decrease in blood pressure … carrying the drug Attempt to aspirate or drain the IV tubing to point of injection If there is blood pressure … samples for ABG and serum electrolyte levels Conduct a neurological examination to exclude focal CNS injury

388. On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/blog/ahrqviews/world-patient-safety-day-2024.html
     September 01, 2024 - common individual adverse events for populations with sufficient size for analysis were: 1) worsening pressure … injuries that were present on admission (2021: 4.9 percent, 2022: 6.0 percent), 2) hypoglycemic events

389. Archived: Final Research Plan: Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan17/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd-august-2014
     May 15, 2013 - healthy diet and/or physical activity improve intermediate outcomes associated with CVD (e.g., blood pressure … or impaired fasting glucose, such that >50% of the population is on medication; mean systolic blood pressure … >140 mm Hg, diastolic blood pressure >90 mm Hg, low-density lipoprotein cholesterol >160 mg/dL, or total … CVD, diabetes, hypertension, or hyperlipidemia; mortality) KQ 2: Intermediate outcomes (blood pressure … outcomes include any harms requiring medical attention (e.g., nutritional deficiencies, musculoskeletal injuries

390. Nursing surveillance: a concept analysis | PSNet
     psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
     May 26, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

391. Ed-Catheter-Insertions-Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.doc
     September 10, 2013 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.

392. Examining the meaning of the language used to communicate the nursing hand-off. | PSNet
     psnet.ahrq.gov/issue/examining-meaning-language-used-communicate-nursing-hand
     July 07, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

393. Archived: Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Risk Factors: Behavioral Counseling | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/recommendation/healthful-diet-and-physical-activity-for-cardiovascular-disease-prevention-in-adults-without-known-risk-factors-behavioral-counseling-july-2017
     July 11, 2017 - Behavioral counseling interventions led to improvements in systolic and diastolic blood pressure levels … Eight trials reported on the incidence of important patient events, including falls, injuries, and cardiovascular … One trial in women aged 40 to 74 years reported more injuries among intervention participants over 24 … Screening for high blood pressure in adults: U.S. … The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure.

394. User Guide: Clinical Classifications Software Refined (CCSR) (pdf file)
     hcup-us.ahrq.gov/toolssoftware/ccsr/DXCCSR-User-Guide-v2019-1.pdf
     September 01, 2019 - biliary perforation; noninfective hepatitis • Diseases of the skin and subcutaneous tissue (SKN) – pressure … ulcer of skin; non- pressure ulcer of skin; contact dermatitis • Diseases of the musculoskeletal system … Coding in ICD-10-CM Diagnoses ICD-9-CM codes did not include information on episodes of care for injuries … In contrast, ICD-10-CM coding for injuries often uses a seventh character to distinguish episodes of … to easily distinguish between the different types of encounters when using the CCSR to categorize injuries

395. What can safety cases offer for patient safety? A multisite case study. | PSNet
     psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study
     February 07, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

396. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet
     psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
     April 17, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

397. 4Nuuvs6Nmztdbgjbg3Elke (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/4NUuvS6nmzTdBgjBg3ELkE
     January 01, 2020 - counseling attributed to an increase in physical activity (41, 55, 65, 70), there were generally no serious injuries … on low-impact activi- ties and increasing activity in small increments can mitigate serious harm or injury … from counseling interventions in older adults or persons at high risk for injury. … Increasing daily walking lowers blood pressure in postmenopausal women. … Blood pressure, stroke, and coronary heart disease.

398. High Reliability | PSNet
     psnet.ahrq.gov/primer/high-reliability
     January 29, 2020 - 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

399. If You Say So: Taking a Syringe at Face Value in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
     January 01, 2015 - Over the next few minutes, the patient's blood pressure skyrocketed to 250/135 mm Hg. … contributors to error in the current case are situational and likely include organizational culture and social pressure … toxic cultures that inhibit communication and assertion of concerns and that exert deep and pervasive pressure … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

400. 2018 National Healthcare Quality and Disparities Report: Appendix A (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-appa5.pdf
     January 01, 2018 - per 1,000 vaginal deliveries without instrument assistance -54.51 -35.20 HCUP 2016 Obstetric trauma … - injury to neonate per 1,000 selected live births 8.00 1.46 HCUP 2016 Accidental puncture or laceration … 18 and over or obstetric admissions 75.00 4.24 HCUP 2016 Reclosure of postoperative abdominal wound … People Relative Difference Z Score Data Source Data Year Reclosure of postoperative abdominal wound … - injury to neonate per 1,000 selected live births 3.3 0.50 HCUP 2016 Adults who had a doctor’s office