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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - He was otherwise healthy with no allergies to medications. … changes,
apnea, muscle weakness, and visual disturbances
Extreme or unexpected increase or decrease in blood … pressure or heart rate
Unexpected or persistent muscle relaxation
Unexpected change, or lack of change … IV carrying the drug
Attempt to aspirate or drain the IV tubing to point of injection
If there is blood … pressure cuff on arm of IV, inflate to slow down entry of drug to central
circulation
Maintain normocarbia
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - He was otherwise healthy with no allergies to medications. … apnea, muscle weakness, and visual disturbances Extreme or unexpected increase or decrease in blood … pressure or heart rate Unexpected or persistent muscle relaxation Unexpected change … carrying the drug Attempt to aspirate or drain the IV tubing to point of injection If there is blood … pressure cuff on arm of IV, inflate to slow down entry of drug to central circulation Maintain
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - Over the course of the night, his blood pressure began to drop. … He was given 2 liters of normal saline with some improvement in his blood pressure. … include color, volume, and frequency of bleeding, a review of comorbid conditions, and an inventory of medications … , particularly antiplatelet and anticoagulant medications. … high-risk endoscopic findings and need for endoscopic therapy at index endoscopy.( 19 ) While specific medications
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Spotlight Case July 2008
Spotlight Case
Near Miss with Bedside Medications
*
*
Source and Credits … Further history revealed that he had recently increased his beta-blocker, a blood pressure medication … Although the patient seemed to have some difficulty in understanding the medications, the pharmacist … Responses to This Case
Patient safety committee recommended that:
Ordering template for “bedside” medications … be modified to include a discontinuation time
ED procedure be modified so that, at discharge, all medications
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psnet.ahrq.gov/periodic-issue/periodic-issue-442
May 29, 2024 - Oncology medications are high-risk due to complexity of patient care and patient polypharmacy. … In this quality improvement project, a multi-component intervention including remote blood pressure monitoring … was found to increase the rate of completed postpartum blood pressure checks among individuals with … Oncology medications are high-risk due to complexity of patient care and patient polypharmacy. … pressure, rapid heart rate, and low oxygen levels.
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - The blood pressure cuff (which was partly fabric and partly nylon) was saturated with so much blood that … Blood pressure cuffs are already known to be reservoirs of bacterial pathogens such as Clostridium difficile … Until the cost-effectiveness of disposable blood pressure cuffs has been established, we can at least … recommend explicit attention to the cleaning and disinfection of blood pressure cuffs between patients … Clostridium difficile contamination of blood pressure cuffs: a call for a closer look at gloving practices
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psnet.ahrq.gov/issue/effect-admission-medication-reconciliation-adverse-drug-events-admission-medication-changes
April 12, 2019 - medication changes (e.g., withholding antihypertensive medication in a patient presenting with low blood … pressure) were also associated with subsequent ADEs, indicating a need for better medication monitoring … December 6, 2010
Results of the Medications At Transitions and Clinical Handoffs (MATCH
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Shortly thereafter, the patient became hypotensive with a systolic blood pressure (BP) of 65 mm Hg. … However, this may not apply to certain high-risk medications (e.g.,
intravenous potassium chloride or … At minimum, a review of medications and doses by the
team should happen every morning (perhaps twice … daily in an ICU) on rounds and should include a
pharmacist.(13,16)
High-risk medications need to be … No checks and balances for high-risk medications High
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - ulcer, presented to the emergency department (ED)
with asymptomatic post-dialysis hypertension, with a blood … pressure of 246/100. … He reported taking his
regular blood pressure medications without any clear trigger for this hypertensive … He was treated
in the ED with hydralazine and clonidine, with mild improvement in blood pressure. … to his SNF, as he remained asymptomatic, with recommendations to resume his usual
antihypertensive medications
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - One week later, the patient was reexamined by the internist and found to have an elevated blood pressure … The physicians later recognized that HIV medications, particularly ritonavir-associated therapy, are … They potentially provide real-time data on recently prescribed and recently dispensed medications. … On a practical level, patients should be encouraged to carry a complete list of their current medications … November 5, 2014
WebM&M Cases
Discontinued Medications
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - Despite aggressive efforts with physical therapy and medications to treat his pain, the patient continued … In patients like the one presented, hypertension must be adequately controlled and antihypertensive medications … Insulin and other diabetic medications should be continued until the day of surgery and then withheld
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psnet.ahrq.gov/issue/association-between-opioid-tapering-and-subsequent-health-care-use-medication-adherence-and
August 25, 2021 - numbers of emergency department visits, and reduced adherence to antihypertensive and antidiabetic medications … intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood … pressure control.
-
psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - His initial vital signs showed a blood pressure of 130/75 mm hg, heart rate of 65 beats per
minute, … He ordered an
echocardiogram for the next morning and prescribed diuretic medications. … 2
qSOFA (quick
Sequential Organ
Failure Assessment
score)
Systolic blood pressure <90 mm Hg Respiratory … 2
MEWS (Modified
Early Warning Score)
Systolic blood pressure Heart rate Respiratory rate
Temperature … pressure) Renal (BUN, creatinine,
urine output) Pulmonary (PaO2/FiO2 ratio)
Hematologic (WBC
-
psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - This meant that a significant period of time passed with no new blood pressure
values being measured … ; however, the patient's blood pressure was documented as unchanged in the
anesthetic record. … A second error in this case was that the previous ("stale") blood pressure value was documented as a … constant blood pressure measurements. … Hence, a stale blood pressure alert would likely decrease patient
safety instead of improving it.
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - His only medications were nasal fluticasone and oral tamsulosin. … Over the next 14 hours, the patient’s blood pressure remained at or below 90/60, and he was described
-
psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - topics are beyond the scope of this
commentary.
12
Background (3)
• IO lines can be used to infuse medications … threshold of muscle is reached when pressure within
the compartment is elevated to 20 mm Hg below the diastolic … pressure or 30 mm Hg below the mean arterial blood pressure
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psnet.ahrq.gov/issue/vital-signs-are-still-vital-instability-discharge-and-risk-post-discharge-adverse-outcomes
September 23, 2020 - This observational cohort study found that patients with abnormal vital signs—temperature, blood pressure … September 27, 2016
Who do hospital physicians and nurses go to for advice about medications
-
psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - She was
overweight but otherwise healthy and was not taking any medications prior to admission. … Over the next few minutes,
the patient's blood pressure skyrocketed to 250/135 mm Hg. … Advances include practice
guidelines, newer and shorter acting medications, new equipment for airway … Yet,
anesthesia is also uniquely vulnerable to medication errors—in that perioperative medications are … The medications most frequently involved included propofol, phenylephrine, and
fentanyl, and errors
-
psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
April 07, 2021 - during transitions of care, screening for drug interactions, providing recommendations) and home-based blood … pressure and blood glucose monitoring. … and closed-loop electronic medication management systems on work processes and safety of controlled medications
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psnet.ahrq.gov/issue/wound-care-teams-preventing-and-treating-pressure-ulcers
June 05, 2019 - Review
Wound-care teams for preventing and treating pressure ulcers.
Citation Text:
Moore ZEH, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2015;9:CD011011. doi:10.1002/14651858.CD011011.pub2.
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