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481. Advances in Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/advances/index.html
     July 01, 2022 - Nozick Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure … Ulcers in Nursing Home Environments (   PDF , 317 KB) Christie Teigland, Richard Gardiner, Hailing

482. Final Progress Report: Impact of state policies on nursing home patient safety culture (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/li-report.pdf
     January 01, 2024 - ongoing quality and safety shortcomings in nursing homes, such as inappropriate medication use and high pressure … ulcer rates.

483. Final Progress Report: Cook County & Rush Developmental Center for Research in Patient Safety: Diagnosis Error Evaluation and Research (DEER) Project (pdf file)
     www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
     January 01, 2025 - The ultimate goal was to apply insights and tools from the fields of medical error prevention, medication … measures failure to diagnose. 4 Although, for each of these AHRQ 20 “sentinel complications” (e.g., decubitus … ulcer, iatrogenic pneumothorax, post-op septicemia, accidental puncture/laceration), timely diagnosis … special theme issue) and which featured both our own work and that of the Massachusetts Coalition for Prevention

484. The Patient Safety Education Project: An international Collaboration (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Emanuel_19.pdf
     February 20, 2008 - rapid response teams, ICU, ER, etc Module 11 Breakout session Chronic care settings: palliative care, pressure … ulcers, falls, etc Module 12 Breakout session Interventional care settings: surgical care; infection

485. Final Progress Report: What About Mom? Using Administrative Data To Develop Measures for Monitoring Healthcare Quality in Pregnancy & Childbirth (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/gregory-report.pdf
     January 01, 2024 - Methods: We modified the AHRQ Indicator Sets (Prevention Quality Indicators, Inpatient Quality Indicators … they were deemed to be not relevant for this population (PSI #2: Death in low-mortality DRGs, PSI #3: Decubitus … ulcer, PSI #4: Failure to rescue, PSI #6: Iatrogenic pneumothorax, PSI #7: Selected infections due … Prevention Quality Indicators Indicator Pregnancy Part of AHRQ Specifications Recommend as Potential … Obstetrical Inpatient Quality Indicators/Obstetrical Prevention Quality Indicators b.

486. Case 2. Central Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-case2.html
     November 01, 2014 - Participation is required in the following priority areas: falls and fall injuries, pressure ulcers,

487. Chartbook on Hispanic Health Care: Slide Presentation—Part 3 | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt3.html
     May 01, 2018 - Promoting the most effective prevention and treatment practices for the leading causes of mortality, … Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions. … Slide 43 Prevention: Receipt of Recommended Vaccinations by Young Children The U.S.

488. Final Progress Report: Failure To Rescue-Patient Safety Learning Lab (FTR-PSLL) (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/blike-report.pdf
     January 01, 2025 - Unlike many other patient safety issues for which evidence-based prevention

489. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
     June 01, 2013 - Agency for Healthcare Research and Quality (AHRQ, via https://psnet.ahrq.gov/glossary) The prevention … The avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes … The prevention of harm to patients. … Complications 26 429 -- Delirium 2 427 -- Nosocomial Infections 3 450 -- Patient Falls 11 428 -- Pressure … Ulcers 5 430 -- Venous Thrombosis and Thromboembolism 0 414 Medication Safety 126 416 -- Medication

490. Department of Health and Human Services National Institutes of Health - National Institute for Research on Safety and Quality (NIRSQ) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/mission/budget/2021/FY_2021_CJ_NIRSQ.pdf
     January 01, 2021 - Services Task Force (USPSTF) is an independent, volunteer panel of nationally-recognized experts in prevention … Rounds on the Web); • AHRQ QuestionBuilder App; • AHRQ’s Safety Program for Nursing Homes: On-Time Pressure … Ulcer Prevention; • Common Formats (standardized specifications for reporting patient safety events … Initial use cases will focus on issues surrounding maternal morbidity and mortality, including prevention … Program Portrait: Recommendation on Preexposure Prophylaxis for Prevention of Human Immunodeficiency

491. QDR 2014: Chartbook for Hispanic Health Care, Part 3 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pdf
     June 01, 2014 - Promoting the most effective prevention and treatment practices for the leading causes of mortality … Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National … Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions

492. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009–2012
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt3.pptx
     September 19, 2015 - Promoting the most effective prevention and treatment practices for the leading causes of mortality, … Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National … medical care, by race/ethnicity, 2013 and January-June 2014 Source: Centers for Disease Control and Prevention … restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions.

493. Final Progress Report: Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/gallagher2-report.pdf
     January 01, 2024 - Hence, when a team was discussing a subject such as prevention of future errors, the segment was not … to fix it Policy: appeal to policies or guidelines to prevent errors Pharmacy: involve pharmacy in prevention

494. Confidential Physician Feedback Reports: Designing for Optimal Impact on Performance (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
     March 01, 2016 - in hospitals, as well as related component measures, such as an A1c value less than 8 percent, and pressure … ulcer rate, for primary care clinicians and hospitals, respectively

495. Final Progress Report: REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/oleary-report.pdf
     January 01, 2024 - hospitalized general medical patients, including adverse drug events, hospital acquired infections, pressure … ulcers, and falls.

496. Final Progress Report: Improving Medication Management Practices and Care Transitions Through Technology (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/feldman-report.pdf
     January 01, 2024 - medication management module was not mandatory, and other more urgent clinical situations (e.g., a worsened pressure … ulcer) with their associated modules may well have taken precedence.