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401. Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study. | PSNet
     psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
     September 23, 2020 - March 5, 2025 A randomized trial of a multifactorial strategy to prevent serious fall injuries … May 29, 2024 WebM&M Cases Under Pressure: Delayed Diagnosis

402. An intervention to enhance nursing staff teamwork and engagement. | PSNet
     psnet.ahrq.gov/issue/intervention-enhance-nursing-staff-teamwork-and-engagement
     June 21, 2010 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

403. Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study. | PSNet
     psnet.ahrq.gov/issue/strength-safety-measures-introduced-medical-practices-prevent-recurrence-patient-safety
     May 01, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

404. What are the experiences of team members involved in root cause analysis? A qualitative study. | PSNet
     psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
     August 16, 2023 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

405. Final Research Plan: Healthy Weight and Weight Gain In Pregnancy: Behavioral Counseling Interventions | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/healthy-weight-and-weight-gain-during-pregnancy-behavioral-counseling-interventions
     July 26, 2018 - infant mortality (including stillbirth), maternal morbidity (e.g., postpartum hemorrhage, perineal trauma … , depression), infant morbidity (e.g., birth trauma, shoulder dystocia, respiratory distress syndrome … delivery) KQ 3: Harms associated with interventions, (e.g., anxiety, stigma, maternal musculoskeletal injuries … changes (e.g., physical activity level) KQ 2: Cardiometabolic measures (e.g., glucose level, blood pressure

406. Microsoft Word - POA Methods 11_01.doc (pdf file)
     hcup-us.ahrq.gov/reports/methods/2011_05.pdf
     January 01, 2011 - The POA indicator is only required for the external cause of injury code if the injury is reported as … Identifying pre-existing wounds at the POA skin assessment represent a special challenge, since a deep … Of the last 16 reported patients with a pressure ulcer, only 25% were recorded with an ICD- 9-CM pressure … admission indicators/hospital-acquired conditions policy: a consensus paper from the International Expert Wound … Advances in Skin & Wound Care. 2008; 21(10): 469-478.

407. A Unit Guide To Infection Prevention for Long-Term Care Staff | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-prevent.html
     March 01, 2017 - Infections cause pain, injury, disability, and sometimes even death, and can be very expensive to treat … signs, such as— Increased temperature Changes in respiration or pulse rate Changes in blood pressure … resident, if needed, that the law requires the use of safety lancets and needles to prevent needle stick injuries … Make sure that wounds are covered. Contain any urine, stool, or wound drainage. … An LTC facility must have negative pressure rooms and a respiratory fit-test program in order to safely

408. Where's the Feeding Tube? | PSNet
     psnet.ahrq.gov/web-mm/wheres-feeding-tube
     September 01, 2003 - Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury … Because of the injuries, he was unable to swallow and had to receive nutrition through a nasojejunal … Perforation March 15, 2023 WebM&M Cases Under Pressure … Post-Tracheostomy Care May 29, 2024 WebM&M Cases Under Pressure

409. Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention. | PSNet
     psnet.ahrq.gov/issue/root-causes-adverse-drug-events-hospitals-and-artificial-intelligence-capabilities-prevention
     May 20, 2020 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

410. Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project. | PSNet
     psnet.ahrq.gov/issue/improving-communication-hospital-skilled-nursing-facility-through-standardized-hand-quality
     September 08, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

411. Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. | PSNet
     psnet.ahrq.gov/issue/differences-hospitals-workplace-violence-incident-reporting-practices-mixed-methods-study
     January 19, 2022 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

412. Interventions to Prevent Falls in Community-Dwelling Older Adults: USPSTF Recommendation Statement (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/h-w99jVsodSL33kV2h2_qW
     April 17, 2018 - assessment using a combination of various components, such as balance, gait, vision, postural blood pressure … assessment using a combination of various components, such as balance, gait, vision, postural blood pressure … Web-based Injury Statistics Query and Reporting System (WISQARS). http://www.cdc.gov/injury/ wisqars/ … J Trauma. 2001;50(1):116-119. 4. Alexander BH, Rivara FP, Wolf ME. … National Center for Injury Prevention and Control.

413. Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. | PSNet
     psnet.ahrq.gov/issue/identifying-safety-practices-perceived-low-value-exploratory-survey-healthcare-staff-united
     February 03, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

414. Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals. | PSNet
     psnet.ahrq.gov/issue/visitor-behaviors-can-influence-risk-patient-harm-analysis-patient-safety-reports-92
     September 01, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

415. A National Web Conference on Transitions in Care (pdf file)
     digital.ahrq.gov/sites/default/files/docs/2010-02-24%20Transitions%20In%20Care%20(4).pdf
     January 01, 2010 - Ibuprofen) 800mg 1 pill by mouth with food pain Zestril© (Lisinopril) 10mg 1 pill by mouth blood pressure … Apresazide© (HCTZ) 25mg 1 pill by mouth blood pressure Nifedical XL© (Nifedipine) 30 mg 1 pill … by mouth blood pressure Protonix© (Pantoprazole) 40 mg 1 pill by mouth indigestion EACH DAY follow … Medical School and the  Associate Director of the Meyers Primary Care Institute Adverse Drug Events injury … Transitions In Care Adverse Drug Events�injury resulting from a medical intervention related to a drug

416. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
     psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
     September 24, 2024 - Carole Stockmeier:  Patients come to us with faith, hope, and trust that we will restore health and heal wounds … safety culture and found a 37% increase in reporting, and decreases in preventable harm: 39% decrease in injuries … with falls, 37% fewer pressure injuries and a 34% reduction in central line-associated blood stream … For instance, a hospital may focus on eliminating severe pressure injuries as a preventable harm, but

417. Screening for and Management of Obesity in Adults: USPSTF Recommendation Statement (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/Bd9Cgr5WNueNbmfsPxUKDP
     September 01, 2012 - interventions also demon- strated some improvement in intermediate health out- comes, such as blood pressure … weight-loss interventions had a minimal effect on lipid outcomes and showed small reductions in blood pressure … The trials found no evidence that weight-loss interventions are associated with serious injuries or an … Questions and Answers: Orlistat and Severe Liver Injury. Rockville, MD: U.S. … Orlistat and acute kidney injury: an analysis of 953 patients [Letter].

418. Nursing Intervention to Remove Non-necessary Urinary Catheters
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-040814.pptx
     January 01, 2013 - remove the catheter shortly after the surgery is completed 27 Assist Healing of Perineal and Sacral Wounds … end-of-life: depends on what the patient perceives as more comfortable 29 Required Immobilization for Trauma … or Surgery Examples include: Unstable thoracic or lumbar spine Multiple traumatic injuries, such … unit (e.g., congestive heart failure receiving diuretics ) Incontinence without sacral or perineal pressure … ICU, or different non-ICU) Partnering with other stakeholders (case managers, physical therapists, wound

419. Ad-Br2Otj67Fendhhkltpa (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/aD-Br2oTJ67FeNdHHkLtPA
     one) Premature aging, wrinkling of the skin Respiratory infections and asthma High blood pressure … � HighHighHighHigh � (tick one) Hangovers, aggressive and violent behaviour, accidents and injury … Anxiety, paranoia, panic, depression Decreased memory and problem solving ability High blood pressure … vision Flu like symptoms, sinusitis, nosebleeds Indigestion, stomach ulcers Accidents and injury … tactile, olfactory Difficulty sleeping Nausea and vomiting Increased heart rate and blood pressure

420. The Unfamiliar Catheter | PSNet
     psnet.ahrq.gov/web-mm/unfamiliar-catheter
     November 01, 2006 - demonstrates that misuse of an unfamiliar medical device can lead to potentially devastating patient injury … and secondary emotional trauma for the involved health care professional. … In one hospital, direct observation of 50 nurses flushing a CVC with a positive pressure adapter revealed … Take-Home Points Unfamiliarity with a CVC can lead to a serious patient injury and have a profound … Medical device related deaths and injuries should be reported to the FDA .