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461. Views of Emergency Medicine Trainees on Adverse Events and Negligence: Survey Results from an Emergency Medicine Training Program in a Regional Health Care System Following the National Standard of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Shah_99.pdf
     March 23, 2008 - medical error and adverse events causes: “pneumothorax, retained objects, hospital-acquired infections, decubitus … ulcers, perioperative myocardial infarctions (MIs), line infections, and falls.” … A few examples include pneumothorax, retained objects, hospital-acquired infections, decubitus ulcers

462. Technology for Improving Medication Monitoring in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
     March 09, 2005 - The authors focus on the prevention of delirium and falls, as these are two of the most common preventable … Activities Falls* Nutritional status Dehydration Dental care Feeding tubes† Physical restraints† Pressure … ulcers Psychotropic drug use *RAPs targeted by the intervention … Falls and fall prevention in the nursing home. Clin Geriatr Med 1996 Nov;12(4):881–902. 25. … Causation, correlation, and prevention. Clin Geriatr Med 1996;12 (4):847–58. 29.

463. Chartbook on Healthy Living: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/healthyliving-slides.html
     April 01, 2018 - Centers for Disease Control and Prevention. Meningococcal VIS. … for Chronic Disease Prevention and Health Promotion; 2014. … Atlanta, GA: Centers for Disease Control and Prevention; 2014. … Atlanta, GA: Centers for Disease Control & Prevention; 2014. … Weight loss also may lead to muscle wasting, infections, and increased risk of pressure ulcers.

464. Advancing Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advancing/index.html
     July 01, 2022 - By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary emboli … the health care system up to $20 billion each year, according to the Centers for Disease Control and Prevention

465. Advancing Patient Safety: A Decade of Evidence, Design, and Implementation (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/advancing-patient-safety.pdf
     January 01, 2010 - By using hospital administrative data, PSIs can identify pressure ulcers, postoperative pulmonary … health care system up to $20 billion each year, according to the Centers for Disease Control and Prevention

466. Meeting Minutes, July 24, 2015 | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/events/nac/2015-03-nac/nacmtg0715-minutes.html
     December 01, 2015 - Rothwell, M.B.A., M.S., National Center for Health Statistics, Centers for Disease Control and Prevention … The program will feature the ABCs of cardiovascular prevention. … The agency will fund studies to address a broad range of issues, including pressure ulcers and falls … We have made great advances in health, yet need greater prevention of many conditions. … The Surgeon General's office is interested in creating a culture of prevention.

467. NPSD Data Spotlight: Patterns of Fall Interventions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
     September 01, 2023 - /Surgical Supply, Fall, Healthcare-Associated Infection, Medication or Other Substance, Perinatal, Pressure … Ulcer, Surgery or Anesthesia, and Venous Thromboembolism iii As of September 2023, the total number … Understanding these intervention patterns provides greater insight into current fall prevention practices … Based on current fall prevention research, patients with differing risks of falling would benefit from … Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized

468. Strategies to Better Engineer Safety into Healthcare Delivery (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
     March 06, 2025 - Product Safety Branch, Division of Healthcare Quality & Promotion, Centers for Disease Control and Prevention … Healthcare organizations can use established methods and tools to incorporate hazard anticipation, prevention … Implementation Support Resources AHRQ • Center for Disease Control and Prevention (CDC) Training: … Healthcare-Associated Infections Program (contains multiple resources and toolkits)  • Preventing Pressure … Ulcers in Hospitals: A Toolkit for Improving Quality of Care  • OSHA Safe Patient Handling Information

469. Chartbook on Healthy Living: National Healthcare Quality and Disparities Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/healthyliving/qdr2015-chartbook-healthyliving.pdf
     January 01, 2020 - Centers for Disease Control and Prevention. … for Chronic Disease Prevention and Health Promotion; 2014. … Atlanta, GA: Centers for Disease Control and Prevention; 2014. … Atlanta, GA: Centers for Disease Control & Prevention; 2014. … Weight loss also may lead to muscle wasting, infections, and increased risk of pressure ulcers.

470. Chartbook on Black Health Care: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/qdr-blackhealth-slides.html
     November 01, 2020 - Centers for Disease Control and Prevention. … Centers for Disease Control and Prevention. … are restrained can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions. … Slide 122 Prevention: Receipt of Recommended Vaccinations by Young Children The U.S.

471. Safe Practices for Better Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
     April 01, 2004 - data collection and reporting by States) and “identify a set of patient safety practices critical to prevention … Evaluate each patient upon admission, and regularly thereafter, for his or her risk of developing pressure … ulcers.

472. Final Progress Report:: The National Quality Forum – Annual Meeting 2003 (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/kizer-report.pdf
     January 01, 2024 - disease; immunization; and several areas pertaining to patient safety: hospital-acquired infections, pressure … ulcers, and patient identification. … how the Project Steering Committee recently finalized discussion on various recommendations on the pressure … ulcer prevalence measure; discussed various versions of the Nursing Work Index (e.g., NWI-R, PES-NWI … States Catholic Health Initiatives Catholic Healthcare Partners Centers for Disease Control and Prevention

473. Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb.pdf
     June 02, 2025 - Transitioning Newborns from NICU to Home: Family Information Packet, Appendix B Appendix B: Clinical Materials to Share With Primary Care Providers Diagnoses and Conditions ■ Anemia of Prematurity ■ Apnea of Prematurity ■ Bronchopulmonary Dysplasia ■ Gastroesophageal Reflux ■ Nephrocalcinosis ■ Patent D…

474. Overview of Patient Safety Learning Laboratory (PSLL) Projects | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/index.html
     August 01, 2025 - Identify areas of skin at risk for developing pressure ulcers (recently renamed by expert organizations … of indwelling urinary catheters, central venous catheters, and pressure injuries (formerly called ‘pressure … ulcers’).

475. Emergency Nurses Association content and transcript (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/ena-slides.pdf
     September 01, 2015 - Transcript 25 Quality Improvements Click on each quality improvement program for CAUTI prevention … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that

476. Emergency Nurses Association content and transcript (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/ena-slides.pdf
     September 01, 2015 - Transcript 25 Quality Improvements Click on each quality improvement program for CAUTI prevention … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that

477. Final Progress Report: Making Acute Care More Patient Centered, Patient Safety Learning Laboratory (PSLL) (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/bates3-report.pdf
     January 01, 2024 - Bowel Regimen, Venous Thromboembolism (VTE) Prophylaxis, Opioid Management, Antibiotic Management, Pressure … Ulcer Prevention and Management, Delirium Management, Fall Risk, Vascular Access, Urinary Catheter … Development and Validation of a Fall Prevention Knowledge Test. … and Family in the Three-Step Fall Prevention Process. … Patient Activation Related to Fall Prevention: A Multi-Site Study.

478. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     www.ahrq.gov/downloads/pub/advances/vol2/Hunt.pdf
     July 01, 2004 - Especially important are the opinions of CMS's federal agency TEP partners, Centers for Disease Control and Prevention … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … ulcers* Postoperative cardiac events* Hospital falls** Angiographic adverse events*** Methicillin-resistant

479. Fundamentals of Medicare Patient Safety Surveillance: Intent, Relevance, and Transparency (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Hunt.pdf
     July 01, 2004 - Especially important are the opinions of CMS's federal agency TEP partners, Centers for Disease Control and Prevention … DVT/PE* Hospital acquired UTI** Ventilator associated pneumonia** Adverse drug events ** Pressure … ulcers* Postoperative cardiac events* Hospital falls** Angiographic adverse events*** Methicillin-resistant

480. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
     January 01, 2025 - biases.60,61 We used the modified National Coordinating Council for Medication Errors Reporting and Prevention … National Academy of Medicine, and National Coordination Council for Medication Error Reporting and Prevention … MERP = Medical Error Reporting and Prevention index. … care related (38.6% vs. 4.7%); the most common subtypes were falls (48%), traumatic injury (11%), and pressure … ulcers (12.3%).