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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
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Jeremy P. Feldman, MD; Michael K. Gould, MD, MS | March 1, 2004
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Case Objective…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - She was febrile to 102°F and had a blood pressure of 110/70 mm Hg, which was lower than her usual.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - The patient became hypotensive with a systolic blood pressure (BP) of 65 mm Hg.
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psnet.ahrq.gov/issue/adding-automation-and-independent-dual-verification-reduce-wrong-blood-tube-wbit-events
April 07, 2021 - intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood … pressure control.
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 25, 2023 - Secured But Not Always Safe
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Jonathan S. Jahr, MD; Puya Hosseini | November 1, 2006
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The Case
An 84-year-old healthy woman underw…
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - The patient ultimately regained a pulse but required two vasopressors to maintain her blood pressure … The patient immediately responded, with improved oxygenation and blood pressure.
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
CE/MOC
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.
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Elizabeth Gould, NP-C,…
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psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
January 01, 2016 - examination, he was afebrile but tachycardic (heart rate 110–120 beats per minute [bpm]) and hypertensive (blood … pressure 155/85 mm Hg). … Over this period, his heart rate increased to greater than 120 bpm and his blood pressure was 175/95 … At this point, the patient was given aggressive intravenous antihypertensives (his blood pressure had
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
March 01, 2005 - auscultation, palpation, and inspection
Positioning the patient is difficult due to decreased mobility
Blood … pressure readings may be inaccurate when wrong size cuff used
Pain threshold in obese patients may
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
March 01, 2005 - auscultation, palpation, and inspection
Positioning the patient is difficult due to decreased mobility
Blood … pressure readings may be inaccurate when wrong size cuff used
Pain threshold in obese patients may
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - breaths/minute Oxygen saturation less than 88% Development of a new arrhythmia Mean arterial blood … pressure falls below 65 or rises above 110 mm Hg Systolic blood pressure exceeding 200 mm Hg Symptoms
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - The second patient safety issue relates to removing fluid—volume control and blood pressure. … Based on their self-assessment skills, they get a blood pressure reading, they get a heart rate reading … pressure during dialysis. … pressure. … You had mentioned with the volume control and blood pressure, that you know that the patient is keeping
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
January 16, 2008 - Repeat vital signs in the ED were notable for a slightly low blood pressure and elevated respiratory … The patient was started on IV norepinephrine through a peripheral IV to maintain his blood pressure, … Not knowing that the patient required pressors to maintain his blood pressure and that he was likely
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
March 14, 2018 - patient.( 12 ) Furthermore, the operative field may appear dry during the procedure when the patient's blood … pressure is low, only to have significant bleeding later emerge when severe hypertensive pressures return
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Heart rate
>24 or <10/minuteRespiratory rate
Systolic >155 or <80 mm Hg
Diastolic >105 or <45 mm Hg
Blood … pressure
Altered mental status
Based on Shields et al. (2016)
Recognition: Early Action on Obstetric
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
November 17, 2010 - Hyperglycemia and Switching to Subcutaneous Insulin
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Tosha Wetterneck, MD, MS | December 1, 2015
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The Case A 47-year-old man with…
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
March 13, 2013 - CVC Removal: A Procedure Like Any Other
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Michelle Feil, MSN, RN | June 1, 2014
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The Case
A 27-year-old man with a history of Behç…
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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - Spotlight
Spotlight
Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong
Source and Credits
• This presentation is based on the October 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary…
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psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis
September 12, 2018 - Review
Classic
Medical device-related pressure ulcers: a systematic review and meta-analysis.
Citation Text:
Jackson D, Sarki AM, Betteridge R, et al. Medical device-related pressure ulcers: A systematic review and meta-analysis. Int J Nurs Stud. 2019;92:109-120…
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psnet.ahrq.gov/web-mm/dangerous-dialysis
August 01, 2014 - ( 4 ) Risk factors for falls included patient age, number of comorbidities, having a lower systolic blood … pressure before starting dialysis, and a history of falls.( 4 ) In addition, after dialysis sessions … , hemodynamic shifts can lead to transient hypotension (low blood pressure) and dizziness.( 4 ) The fall