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461. SOPS Nursing Home Survey: What You Need To Know - Nicholas Castle, Ph.D., M.H.A., FGSA (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
     January 01, 2006 - Hospitals ►Moving, Transferring, or Lifting Residents ►Medication errors ►Falls ►Pressure ulcers ►Sanitation … Patient Safety Culture in Nursing Homes • Safety culture influences staff as well as residents ► Overall injury

462. Triggers contributing to health care clinicians' disruptive behaviors. | PSNet
     psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
     June 24, 2020 - The most frequent triggers included pressures from high census; environmental overload; chronic, unresolved … Multifactorial interventions to reduce duration and variability in delays to identification of serious injury … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

463. Exploring stakeholder perceptions around implementation of the Operating Room Black Box for patient safety research: a qualitative study using the theoretical domains framework. | PSNet
     psnet.ahrq.gov/issue/exploring-stakeholder-perceptions-around-implementation-operating-room-black-box-patient
     November 04, 2020 - mostly supportive of the OR Black Box, but several potential barriers were identified, such as time pressures … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury … August 8, 2012 Role of intraoperative cholangiography in avoiding bile duct injury. … March 31, 2010 Laparoscopic bile duct injury: understanding the psychology and heuristics

464. Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? | PSNet
     psnet.ahrq.gov/issue/rates-adverse-events-hospitalized-patients-after-summer-time-resident-changeover-united
     June 22, 2022 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … March 23, 2012 Injury and death associated with incidents reported to the Patient Safety … Hospitals Medicine Medication Errors/Preventable Adverse Drug Events Nosocomial Infections Pressure

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45036/psn-pdf
     February 15, 2017 - 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

466. Interventions to Prevent Falls in Community-Dwelling Older Adults: US Preventive Services Task Force Recommendation Statement (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/gW6MHsqzJ7Nn4a7S6S_9UN
     June 04, 2024 - IMPORTANCE Falls are the leading cause of injury-related morbidity and mortality among older adults in … (170 fall-related injuries per 1000 older adults). … disease events, cardiovascular disease mortality, and all- cause mortality, as well as lower blood pressure … assessment using a com- bination of various components, such as balance, gait, vision, pos- tural blood pressure … initial assessment of modifiable risk factors for falls (eg, balance, gait, vision, postural blood pressure

467. 50-State Environmental Scan of State Publications Documenting Racial and Ethnic Disparities in Health Status and Health Care
     hcup-us.ahrq.gov/reports/race/50_state_r_e_rpt.jsp
     July 01, 2016 - and Illnesses, Census of Fetal Occupational Injuries, Current Population Survey), DPH Infectious Diseases … Physical Activity, Mental Health, Tobacco Use, High Blood Pressure, Obesity, Stroke, Heart Disease … Asthma, Cancer, Cardiovascular Disease, Diabetes, Obesity, HIV/AIDS, Infant Mortality, Unintentional Injuries … Vehicle Deaths, Deaths of Children 1-17, Deaths of teens 15-17, Tobacco Use, General Nutrition, Blood Pressure … include "ABC's of Heart Attack", "Heart Disease Prevention", "Preventing and Controlling High Blood Pressure

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73665/psn-pdf
     September 01, 2021 - The most common safety events included pressure injuries or other skin integrity events, falls, and

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60027/psn-pdf
     January 01, 2021 - Improvements in medication errors and hospital- acquired pressure injuries were observed, but employee

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/843054/psn-pdf
     January 25, 2023 - The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73998/psn-pdf
     October 27, 2021 - Blood products and intravenous fluids were infused under pressure into the external jugular intravenous … efflux of solutions from a vessel into the surrounding tissue during an infusion” and may cause grave injury … If an internal jugular venous catheter is placed, the venous pressure should be transduced, and the … Outcomes and management of peripheral intravenous infiltration injuries. Hand (NY). … Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma.

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60551/psn-pdf
     January 01, 2021 - The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates

473. Getting rid of "never events" in hospitals. | PSNet
     psnet.ahrq.gov/issue/getting-rid-never-events-hospitals
     April 25, 2016 - Never events are devastating and preventable, and health care organizations are under increasing pressure … September 21, 2005 "Near injury" alters procedures at Virginia Mason.

474. Table 10: Outcome Indicators by Selected Home and Community-Based Services 1915(c) Waiver Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab10.html
     February 01, 2023 - Composite: ACSC Overall Yes 22,422 20,395 25,160 No 18,138 19,018 17,666 Pressure … 7,607 Composite: ACSC Overall 20,384 19,444 14,877 19,094 19,184 20,443 Pressure

475. Resource List - AHRQ Nursing Home Survey (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
     April 01, 2023 - Falls Management Program http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Provider Fax Report and Orders http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … professionals/onthejob/falls.asp http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/index.html http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx … /fallspx/fallspxmanapb10pcp.html http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries

476. Check the Anesthesia Machine | PSNet
     psnet.ahrq.gov/web-mm/check-anesthesia-machine
     August 01, 2006 - 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.

477. Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017.html
     November 01, 2017 - Comparison to 2010 AHRQ estimates Summary Despite advancements in infection control and injury prevention … can stem from diagnostic or treatment errors (e.g., failure to follow antibiotic protocols); medical injuries … Beginning in 2008, CMS identified the HACs (e.g., CAUTI, falls and trauma, surgical site infection) for … Falls Fall during an inpatient admission, with or without injury, whether or not fall was assisted. … Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s) present

478. Obstetric Quality and Safety. | PSNet
     psnet.ahrq.gov/issue/obstetric-quality-and-safety
     February 25, 2009 - November 10, 2010 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852807/psn-pdf
     August 30, 2023 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … new-recommendations-duty-hours-acgme-task-force decreased risk of motor vehicle crash involvement and needlestick injury … Simplify the treatment when tired or under time pressure When clinicians are tired or pressured for … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours?

480. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
     January 29, 2021 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … ; this change was associated with decreased risk of motor vehicle crash involvement and needlestick injury … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours? … Effects of coffee on ambulatory blood pressure in older men and women: a randomized controlled trial.