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61. Transfusion "Slip" | PSNet
    psnet.ahrq.gov/web-mm/transfusion-slip
    February 01, 2007 - Her blood pressure remained low despite wide-open crystalloid infusions, and she had signs of peritoneal

62. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
    April 01, 2009 - Spotlight Case July 2008 Spotlight Case Breakage of a PICC Line * * Source and Credits This presentation is based on the April 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Vesselin Dimov, MD Creighton University Editor, AHRQ WebM&M: …

63. Blind Spot | PSNet
    psnet.ahrq.gov/web-mm/blind-spot
    July 30, 2020 - Blind Spot Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Lorri A. Lee, MD | June 1, 2005 View more articles from the same authors. The Case A 36-year-old woman with no significant past medical history underwent righ…

64. Towards international consensus on patient harm: perspectives on pressure injury policy. | PSNet
    psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-policy
    September 23, 2015 - Review Towards international consensus on patient harm: perspectives on pressure injury policy. Citation Text: Jackson D, Hutchinson M, Barnason S, et al. Towards international consensus on patient harm: perspectives on pressure injury policy. J Nurs Manag. 2016;24(7):902-914. doi:10.111…

65. Physical Diagnosis: A Lost Art? | PSNet
    psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
    December 17, 2014 - recorded as follows:            General: Mild respiratory distress with audible wheezing Vitals: Blood … pressure 110/62, Pulse 106, Respiratory rate 18, Temp 37.8°, Room air saturation 100% HEENT: Crusting … In one study, 90% of patients expected their blood pressure to be measured and their heart, lungs, abdomen … resident in charge of his care incidentally noted subcutaneous crepitus in the arm while measuring the blood … pressure.

66. A Stroke of Error | PSNet
    psnet.ahrq.gov/web-mm/stroke-error
    December 01, 2015 - Appreciate the relationship between elevated blood pressure and stroke in the acute setting. … On presentation, he was noted to have a systolic blood pressure of 220 mm Hg and word-finding difficulties … Blood pressure is commonly elevated in patients with acute stroke and may be related to the stress of … .( 5 ) Extreme elevations of blood pressure can result in end-organ damage manifesting as cerebral, cardiac … In the acute setting, it may be difficult to differentiate between blood pressure elevation as the primary

67. Paradoxical Pulse | PSNet
    psnet.ahrq.gov/web-mm/paradoxical-pulse
    May 01, 2013 - presented to the emergency department (ED) for evaluation where he was noted to be afebrile with a blood … pressure of 113/66, heart rate of 95, and an oxygen saturation of 99% on room air. … Pulsus paradoxus is an exaggeration of the physiologic drop in blood pressure with inspiration. … Elevated arterial blood pressure in cardiac tamponade. N Engl J Med. 1992;327:463-466.

68. Getting the Diagnosis Both Right and Wrong | PSNet
    psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
    February 18, 2015 - The patient's blood pressure improved with fluids. … Six hours after admission, the patient's blood pressure started to drop, requiring further intravenous

69. PowerPoint Presentation (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
    May 01, 2017 - On examination, he was afebrile but tachycardic (heart rate 110–120 bpm) and hypertensive (blood pressure … 1: Diagnostic Delay (4) Over this period, his heart rate increased to greater than 120 bpm and his blood … pressure was 175/95 mm Hg. … Diagnostic Delay (8) At this point, the patient was given aggressive intravenous antihypertensives (his blood … pressure had risen to 180/100 mm Hg).

70. A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals. | PSNet
    psnet.ahrq.gov/issue/comprehensive-program-reduce-rates-hospital-acquired-pressure-ulcers-system-community
    May 12, 2021 - Study A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals. Citation Text: Englebright J, Westcott R, McManus K, et al. A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community Hospita…

71. The Hidden Danger of Unseen Intravenous Catheters | PSNet
    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 03, 2007 - The Hidden Danger of Unseen Intravenous Catheters Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Marissa G. Vadi, MD, MPH, and Mathew R. Malkin, MD | October 27, 2021 View more articles from the same authors. The Cas…

72. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet
    psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
    March 29, 2023 - Assessing the position of the eyes, the pupil diameter, the frontalis muscle and the heart rate and blood … pressure can help the anesthesiologist assess the depth of anesthesia. 25 Processed electro-encephalography

73. The Pharmacist's Role in Medication Safety | PSNet
    psnet.ahrq.gov/primer/pharmacists-role-medication-safety
    March 14, 2018 - adherence Provide health and wellness services Deliver direct health and wellness service Blood … pressure screenings can reveal poorly controlled hypertension Medication management Comprehensive … ; provide guidance regarding medication therapy Pharmacist may detect dangerously low or high blood … pressure and recommend changes in medication therapy and thereby prevent harm Coordinating care

74. Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx (pdf file)
    psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…

75. Amended Lab Results: Communication Slip | PSNet
    psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
    May 09, 2018 - year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension and a blood … pressure of 140–150/90 mm Hg. … Preeclampsia is diagnosed by elevated blood pressure (consistently greater than 140/90 mm Hg) and proteinuria

76. Too Many Cooks Spotlight Pdf (pdf file)
    psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - not ICU) with only routine vital signs and nursing checks every four hours • Patient’s systolic blood … pressure after transfer was 60 mmHg – On-call Trauma Surgery team was notified one hour later and

77. Good Catch in the Operating Room | PSNet
    psnet.ahrq.gov/web-mm/good-catch-operating-room
    November 08, 2023 - About halfway through the procedure, the anesthesiologist noticed that the patient's blood pressure was … anesthesiologist administered a bolus of intravenous fluids, but over the next few minutes the patient's blood … pressure continued to drop. … the first challenge occurred when the anesthesiologist alerted the surgeon during the initial drop in blood … pressure.

78. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
    June 01, 2013 - given fentanyl, etomidate, and rocuronium. 4 5 Case: Emergency Error (2) Almost immediately, her blood … pressure dropped to 60/30 mm Hg. … She ultimately regained a pulse but required high doses of vasopressors to maintain her blood pressure

79. A Pill Organizing Plight | PSNet
    psnet.ahrq.gov/web-mm/pill-organizing-plight
    December 01, 2011 - system, including empty slots for upcoming days as well as slots that contained a higher number of blood … pressure medications than the patient was supposed to take. … The resident also discovered that an old blood pressure medication (a beta-blocker), which had been stopped … As a result of these problems, on some days the patient was taking up to five blood pressure pills when … pressure medications.

80. In Conversation With... José A, Morfín, MD, FASN | PSNet
    psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
    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