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441. 162-Example-Completed-Learning-Defects-Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
     October 01, 2024 - Current: He was found unconscious at home after a suspected syncopal episode with injury to his chest … First vitals included a blood pressure of 75/40, temperature of 38.5°C, heart rate of 110 beats per minute … His blood pressure continued to remain low, and it was decided to place a central line and begin a vasopressor

442. Acute Respiratory Arrest in Pregnancy | PSNet
     psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
     August 15, 2018 - Two days prior to admission, the patient presented to the obstetrics clinic with blood pressures (BPs … marked increase in her plasma volume with resultant increase in her preload (increased left atrial pressure … orders for type and frequency of blood tests, fetal monitoring, and surveillance of symptoms and blood pressure … Criteria for E stablishing Severe Preeclampsia.* • Persistent blood pressure above 160/110 mm … Related Resources WebM&M Cases Uterine Artery Injury

443. Resources by Safety Topic | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/type-harm.html
     April 01, 2025 - Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure … Center for Disease Control and Prevention (CDC) Stopping Elderly Accidents, Deaths & Injuries (STEADI … Back to Contents Pressure Ulcers AHRQ Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving … Quality of Care This resource assists hospital staff in implementing effective pressure ulcer prevention

444. Communication: Obstetric Hemorrhage (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_3-communication-speaker-notes.pdf
     July 01, 2023 - 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 … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … Her blood pressures have remained normotensive, and she has had good reflexes throughout the shift. … 2023 Communication Obstetric Hemorrhage Communication is… Maternal and Perinatal Deaths and Injuries

445. Slide 1 (pdf file)
     hcup-us.ahrq.gov/datainnovations/clinicaldata/MPinepresentation.pdf
     September 22, 2010 - For accidents (i.e., E codes), POA codes are based on the relation of the time of injury to the time … Therefore, POA=Y only when injury occurs prior to admission. … Composite Scores Enter 4 or More Models Vital Signs, Other Lab Data, Scores • Pulse (8) • Blood Pressure

446. Table 18A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18.html
     December 01, 2012 - Composite: ACSC Overall 24,317 16,815 18,770 19,809 22,527 15,998 23,953 16,701 Pressure

447. Microsoft Word - QDR 2014 HCUP Short Methods Report_041015_FINAL.docx (pdf file)
     hcup-us.ahrq.gov/reports/methods/2015_02.pdf
     January 01, 2015 - In addition the QIs for pressure ulcer (PDI 2 and PSI 3) are not reported for any year because numerous … E Codes: Another issue relates to external cause-of-injury reporting. … Incidence measures PDI 2 (pressure ulcer), PDI 3 (foreign body), and PDI 13 (transfusion reaction) are … PSI 17 Birth trauma - injury to neonate per 1,000 live birthsa a Consistent with the AHRQ PSI software … The AHRQ PSI for pressure ulcers is excluded.

448. Care Coordination Quality Measure for Primary Care (CCQM-PC) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/ccqmpc/ccqm-pc-survey-instructions.pdf
     July 01, 2016 - most of your usual health care needs and who you normally see when you need care for a new illness or injury … being able to walk a flight of stairs without losing your breath, or target rates—for example, a blood pressure … In the last 12 months, if you had an illness or injury, how often did your primary care provider or … 1 Never 2 Sometimes 3 Usually 4 Always 5 I did not have an illness or injury in the last … High blood pressure or hypertension? Congestive heart failure? Coronary artery disease?

449. Making Health Care Safer II, Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
     March 01, 2013 - “common;” examples include falls, venous thromboembolism (VTE), potential adverse drug events, or pressure … The scope must also consider the severity of each event; for instance, most falls do not result in injury … patient safety target, such as adverse drug events, or general clinical topics, such as preventing pressure … High (hypoglycemia) Low-to- moderate NA Interventions to prevent contrast-induced acute kidney injury … Common/ Moderate High Moderate (bleeding) Low Little/Moderate Preventing patient death or serious injury

450. Translating Hypertension Guidelines into Practice: Development of Interoperable Clinical Decision Support - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/u18hs026849-dorr-final-report-2022.pdf
     January 01, 2022 - First, hypertension is known as the ‘silent killer’, 1 as elevated blood pressures are asymptomatic, … substantial increase in adverse events such as dizziness, falls, electrolyte disturbances and acute kidney injury … Data adequacy: Adult patients with a diagnosis of hypertension or 4 blood pressures > 140/90 were selected … Protocol for blood pressures Figure 7. … Diagnosis and monitoring had several challenges – from the unreliability of office blood pressures to

451. Archived: 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/recommendation/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd-august-2014
     August 26, 2014 - blood pressure, and aspirin use when appropriate. … Systolic and diastolic blood pressures decreased by 1 to 3 mm Hg and 1 to 2 mm Hg, respectively. … interventions, a few participants reported fatigue, muscle soreness, or other minor musculoskeletal injuries … In Brief: Your Guide to Lowering Your Blood Pressure With DASH. … Blood pressure, stroke, and coronary heart disease.

452. Analysis of Emergency Department Visits During the October 2017 Wildfires in Northern California (pdf file)
     hcup-us.ahrq.gov/reports/ataglance/HCUPanalysisCA2017Wildfires.pdf
     August 19, 2019 - (Including Burns) Figures 8a–8e present emergency department visits for the initial encounter of injuries … The scale for the y-axis indicating ED visits for injuries ranges from 0 to a maximum of 1,000. … ICD-10-CM Code Range Injury Code Range Description S00- to S99 Injuries head, neck, thorax, abdomen … effects of health and light, hypothermia, other effects of reduced temperature, effects of air and water pressure … unspecified effects of other external causes and adverse effects T79- Certain early complications of trauma

453. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
     April 02, 2025 - of On-Time This version of On-Time introduction is for training Facilitators who have not had pressure …  It is more difficult for staff to identify which residents are at risk for a fall or pressure … electronic reports with input from relevant staff (e.g., nursing assistants, director of nursing [DON], wound … weekly basis and encourage multidisciplinary input (e.g., certified nursing assistants [CNAs], DON, wound … when On-Time pressure ulcer prevention reports were integrated into day-to-day workflow

454. Final Recommendation Statement: Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd
     November 24, 2020 - This recommendation applies to adults 18 years or older with known hypertension or elevated blood pressure … (–1.8 mm Hg [95% CI, –2.5 to –1.1]), diastolic blood pressure (–1.2 mm Hg [95% CI, –1.6 to –0.8]), total … trials evaluating physical activity interventions, a few participants reported minor musculoskeletal injuries … There is convincing evidence that counseling interventions improve blood pressure, lipid and fasting … At 12 to 24 mo, the intervention groups showed greater reductions in blood pressure (systolic blood pressure

455. National Web-Based Teleconference on Utilizing Health IT to Improve Medication Management for the Care of Elderly Patients (pdf file)
     digital.ahrq.gov/sites/default/files/docs/medication-management-elderly-slides-081811.pdf
     August 18, 2011 - Preventability of Adverse Drug Events in Two Large Academic Long-term Care Facilities Adverse Drug Events injury … Gastrointestinal 16% Renal/electrolytes 12% Fall with injury … 5% Cardiovascular 4% Fall without injury … I know if I stay off my Verapamil for angina and high blood pressure too long I will start to get pressure

456. E-cigarette Explosion in a Patient Room | PSNet
     psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
     March 15, 2023 - oxygen requirement at home was 2 liters via nasal cannula, and she used a continuous positive airway pressure … Benowitz, MD This case, of a woman who sustained burn injuries from using an electronic cigarette ( … Numerous reports have emerged of fires and explosions caused by e-cigarettes, some resulting in severe injuries … In summary, this case describes a serious injury due to use of an e-cigarette, a known ignition source … Electronic cigarette explosion and burn injuries, US emergency departments 2015–2017.

457. Update on Methods: Insufficient Evidence | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/update-methods-insufficient-evidence
     March 04, 2021 - take up the time available to discuss smoking cessation, or to address an acute problem or a minor injury … Contrast: Application to Screening for High Blood Pressure in Adolescents   Screening for high blood … Considering this information, a clinician might decide in favor of assessing blood pressure routinely … Preventive Services Task Force Recommendation on High Blood Pressure Screening, 2003. … Recommendations for Adults: Heart and Vascular Diseases: Screening for High Blood Pressure.

458. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023-rev.pdf
     January 01, 2023 - An example of additional detail from the Fall module would be the type of injury sustained in a fall … Pressure Ulcers result in harm to the patient by their very nature. … This is unexpected, as pressure ulcers result in harm to the patient by their very nature. … unstageable • A lesion that, on admission, was a suspected Deep Tissue Injury • A pressure ulcer … Pressure Ulcers result in harm to the patient by their very nature.

459. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet
     psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
     February 05, 2020 - Nitrous oxide only flows into the oxygen pipeline when the pressure in the nitrous line is higher than … When pressure in the oxygen line drops below that in the nitrous line, it is possible for an outlet to … The pressure in the oxygen and nitrous oxide pipelines as well as in the cylinders mounted on the anesthesia … When the pressure in the oxygen pipeline drops, a gas outlet may begin to deliver a hypoxic gas mixture … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

460. Recommendation: Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/recommendation/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd
     November 24, 2020 - Risk factors include: dyslipidemia, elevated blood pressure or hypertension, or multiple or mixed risk … (–1.8 mm Hg [95% CI, –2.5 to –1.1]), diastolic blood pressure (–1.2 mm Hg [95% CI, –1.6 to –0.8]), total … trials evaluating physical activity interventions, a few participants reported minor musculoskeletal injuries … There is convincing evidence that counseling interventions improve blood pressure, lipid and fasting … At 12 to 24 mo, the intervention groups showed greater reductions in blood pressure (systolic blood pressure