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psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events-hospitalized-patients-across-two-time-periods
December 14, 2011 - August 14, 2014
Electronic alerts to prevent venous thromboembolism among hospitalized … April 27, 2022
Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - Examples:
pneumothorax from central venous catheter placement
anaphylaxis to penicillin
postoperative … Thus, pneumothorax from central venous catheter placement counts as an adverse event regardless of insertion
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - To provide more nutrition, the physician placed
a central venous line and prescribed intravenous (IV … The LPN on the night shift
mistakenly hooked up the total nutrient fluid prepared for the central line … daughter's concern was
well founded—indeed this total nutrient fluid was to be administered through the central … disconnected the
total nutrient line from the enterostomy tube, and prepared to connect it to the central … daughter (a retired RN) and the RN in charge were present and stopped the LPN from
contaminating the central
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psnet.ahrq.gov/issue/systematic-review-evidence-links-between-patient-experience-and-clinical-safety-and
May 01, 2019 - Economic evaluation of quality improvement interventions for bloodstream infections related to central … March 5, 2014
Practices to prevent venous thromboembolism: a brief review.
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psnet.ahrq.gov/issue/rates-patient-safety-indicators-belgian-hospitals-were-low-generally-higher-us-hospitals-2016
September 13, 2023 - More
Related Resources
Improving appropriate use of peripherally inserted central … More About The Topic
Hospitals
Indwelling Tubes and Catheters
Nosocomial Infections
Venous
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - baseline
Timing: within 5-10 days of heparin exposure
Thrombosis: up to half of patients will develop venous … thrombosis—risk of thrombosis persists for at least 30 days, with up to 50% of patients developing venous … NS for patency of peripheral or central catheters
Heparin still used routinely for flushing dialysis … Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of … of heparin
Clinical presentation of HIT can include isolated thrombocytopenia, isolated arterial or venous
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - therapy is increasingly utilized in the inpatient setting to reduce the incidence of hospital-acquired venous … neuraxial methods result in fewer postoperative cardiac events, pulmonary complications, and cases of venous … Take-Home Points Pharmacologic prophylaxis for venous thromboembolism and neuraxial anesthesia are … Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic … Cases
Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Signs of hemorrhagic shock are low blood pressure, tachycardia, flat neck veins (no central venous filling … clinical features that distinguish tamponade from hypovolemic shock are distended neck veins or elevated venous … Beck's triad—muffled heart tones, jugular venous distention, and hypotension—describe the classic presentation … Kussmaul's sign—jugular venous distention upon inspiration—may also be seen in pericardial tamponade
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psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - such study cites the inability of intensive care unit
personnel to accurately determine the jugular venous … pressure (JVP), calling instead for central venous
access for determination of this parameter.(1) In … Clinical assessment of central venous pressure in the critically ill.
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - Venous thromboembolism, ventilator-associated pneumonia, central line–related infection, and urinary … now would be that chlorhexidine be used rather than povidone iodine, and ideally it would be in the central … venous catheter kits. … barriers that we used in the past, and that the large drape be either in the kit or be part of the central … venous catheter kit.
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - point-of-care ultrasound demonstrated marked right
heart strain
8
Case Details (5)
• Arterial and central … venous catheters were placed and she was
given tissue plasminogen activator (tPA)
– Approximately … High incidence of deep venous thrombosis after Achilles tendon rupture: a prospective study. … American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of … J Vasc Surg Venous Lymphat Disord. 2019;7(4):493-500. doi:10.1016/j.jvsv.2018.11.014.
43.
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - These include compliance with hand hygiene, optimal management of central venous and urinary catheters … Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central … venous catheters from hospitals in the Prevention Epicenter Program. … Cases
Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - airway compromise has also been reported with other commonly performed
medical procedures, including central … of the trachea by
a hematoma below the level of the cricoid or from supraglottic edema secondary to venous … The rate of hematoma expansion may be dependent on
the mechanism (e.g., arterial vs. venous bleeding … psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Hematoma formation resulting from either venous … can progress from partial to total very quickly, once critical compression from the hematoma
impairs venous
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Intermittent pneumatic compression devices were placed on both calves to prevent venous thrombosis, but … A doppler ultrasound scan of the right leg was negative for venous thrombosis. … This patient was misdiagnosed as having a deep venous thrombosis and was anticoagulated unnecessarily … Venous thrombosis is usually not associated with such severe pain. … Cases
Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - The patient remained on metoprolol and simvastatin
in addition to enoxaparin for deep venous thrombosis … In a prospective regional study of 580
patients, no patient who received venous thromboembolism prophylaxis … category: the patient was appropriately risk stratified prior to surgery, she received prophylaxis
for venous … Iatrogenic
pneumothorax
Pneumothorax ("collapsed
lung") due to a procedure
such as insertion of a
central … venous catheter
Discharges with ICD-9-CM code of 512.1 in any secondary
diagnosis field per 100 medical
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - To provide more nutrition, the physician placed a central venous line and prescribed intravenous (IV) … The LPN on the night shift mistakenly hooked up the total nutrient fluid prepared for the central line … daughter's concern was well founded—indeed this total nutrient fluid was to be administered through the central … , disconnected the total nutrient line from the enterostomy tube, and prepared to connect it to the central … daughter (a retired RN) and the RN in charge were present and stopped the LPN from contaminating the central
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psnet.ahrq.gov/node/74253/psn-pdf
January 12, 2022 - comparing 12 months of data from just prior to
the pandemic to six months of data during the pandemic, central … with a higher
percentage of COVID-19 admissions.8 Other studies have found that urinary catheter and central … venous
catheter use increased during the pandemic6,9 and that COVID-19 patients are at a higher risk … hospitalization of COVID-19 patients, but also to
challenges in maintaining those devices (catheters, central … Coronavirus disease 2019 (COVID-19) pandemic, central-line-
associated bloodstream infection (CLABSI
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - A kidney ultrasound on post procedure day (PPD) 3 revealed a central hematoma, decreased systolic velocity … ureter), and thrombosis can result from technical problems such as intimal dissection or arterial or venous … practice guidelines recommend using ultrasound to narrow the differential diagnosis, which includes venous … Cases
Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - partner, Perot Systems, which basically tracks device days
and hospital-associated infections for central … venous lines, catheter-associated urinary tract infections
(UTIs), and ventilator-associated pneumonias … administration of the
hospitals engaged them—the intensivists in the ICUs and the surgeons placing central … won't tell you that there weren't a few doctors here and there who
didn't want a nurse assisting in a central … structure things so that, at the level of an individual hospital, people feel comfortable with
the central
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - The patient remained on metoprolol and simvastatin in addition to enoxaparin for deep venous thrombosis … In a prospective regional study of 580 patients, no patient who received venous thromboembolism prophylaxis … category: the patient was appropriately risk stratified prior to surgery, she received prophylaxis for venous … Iatrogenic pneumothorax Pneumothorax ("collapsed lung") due to a procedure such as insertion of a central … venous catheter Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field per