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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - input (head injury, ingestion of central nervous system
depressant, adverse effect of procedural sedation
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
March 06, 2025 - Strategies to Better Engineer Safety into Healthcare Delivery
Page 1 of 17
Engineering Safe Practices Affinity Group
Strategies to Better Engineer Safety into
Healthcare Delivery
March 6, 2025
Table of Contents
Problem Statement ...............................................................................…
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www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-slides.html
February 01, 2025 - Bronchodilators, sedation, or very rarely paralysis may be necessary. … Sedation and paralysis should be used very sparingly, especially paralytics, unless severe ARDS present
-
www.ahrq.gov/news/newsletters/e-newsletter/923.html
July 01, 2024 - Ethnic disparities in deep sedation of patients with acute respiratory distress syndrome in the United
-
www.ahrq.gov/patient-safety/resources/learning-lab/re-engineering-postnatal-unit-care-long-desc.html
April 01, 2025 - observational retrospective study of adverse events and behavioral outcomes during pediatric dental sedation
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www.ahrq.gov/hai/cauti-tools/archived-webinars/leveraging-cultural-change-slides.html
December 01, 2017 - Leveraging Cultural Change to Reduce Urinary Catheter Use
Slide Presentation
Slide 1
Leveraging Cultural Change to Reduce Urinary Catheter Use
Linda Greene, RN,MPS,CIC
Manager Infection Prevention
Highland Hospital
Jennifer Tuttle, RN, MSNEd
Adult Critical Care Unit
Tucson Medical Center
Images:…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb1txt.html
December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix B1: The FMP Self-Assessment Tool (Text Description)
Previous Page Next Page
Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction…
-
www.ahrq.gov/sites/default/files/2024-01/bailey-kilbridge-report.pdf
January 01, 2024 - Incidence and nature of adverse
events during pediatric sedation/anesthesia for procedures outside the … operating room: report from the
Pediatric Sedation Research Consortium. … Adverse events associated with procedural sedation and analgesia
in a pediatric emergency department: … Risk reduction in pediatric procedural
sedation by application of an American Academy of Pediatrics/American … Adverse sedation events in pediatrics: a critical
incident analysis of contributing factors.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-comm-assessment.pdf
April 01, 2016 - children who has presented to the hospital’s GI suite to undergo a
procedure under moderate [procedural] sedation … approximately 7 minutes during which she may not
have been breathing adequately, possibly from too much sedation … We now believe that
this blue episode may have been the result of too much sedation medication being
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Meliones_40.pdf
January 01, 2006 - Six Sigma reduced the risk score in moderate sedation from 11.94 to 4.94 and event
probability score … For example, a Six Sigma initiative focused on pediatric moderate sedation decreased the mean
risk score … a
57 percent reduction in cumulative risk and a 60 percent reduction in severity score in pediatric sedation
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
March 01, 2020 - Comparison and agreement between the Richmond
Agitation-Sedation Scale and the Riker Sedation-Agitation … Delirium and sedation recognition using validated
instruments: Reliability of bedside intensive care … Not provided Not provided Low
Khan et al.,
20127
Evaluation of
Richmond
Agitation-
Sedation Scale … (RASS) and
Riker Sedation-
Agitation Scale
(SAS) in
identifying
patients eligible
for delirium … correctly
Fifty intensive care unit
(ICU) nurses evaluated
an ICU patient for pain,
level of sedation
-
www.ahrq.gov/research/findings/factsheets/children/publications/2010.html
October 01, 2014 - Agitation during procedural sedation and analgesia in children.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0197-table6-figs1-2.pdf
July 16, 2015 - However, CT is more widely
available than MRI, is less expensive, and
less likely to require sedation
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0198-table10-figures1-2.pdf
July 16, 2015 - However, CT is
more widely available than MRI, is less expensive,
and less likely to require sedation
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/building-teamwork-transcript.html
December 01, 2017 - They're had their catheter for five days, and they're just too sick to actually come off their sedation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/building-team-transcript.doc
April 08, 2014 - They’re had their catheter for five days, and they’re just too sick to actually come off their sedation
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/transfer.html
September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits
Electronic Reports
Transfer Risk Report
Table 1. Sample High-Risk Transfer Report
Facility Name:
Unit:
Report Date:
Resident Name and Advance Directive Status
# ED Visits Within:
ED Discharg…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - Slide 1
Leveraging Cultural Change to Reduce Urinary Catheter Use
1
Linda Greene, RN,MPS,CIC
Manager Infection Prevention
Highland Hospital
Jennifer Tuttle, RN, MSNEd
Adult Critical Care Unit
Tucson Medical Center
Learning Objectives
Describe the way in which improvement in the clinical culture can facilitate e…
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/139-nv-hap-prevention-essential-one-pager.docx
October 01, 2024 - NV-HAP Prevention Essential Practices1-4
Practice routine oral care.4,5-8
Staphylococcus aureus is a common pathogen in dental plaque.
Conduct an individualized assessment and plan for each patient considering their ability to perform self-care independently.
At minimum, the oral care regimen should include: toothbrus…
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Appendix C. Case Study and Program Examples
Previous Page Next Page
Table of Contents
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
Chapter 1. Introduction and Program Over…