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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - Intubation was attempted multiple times after the patient arrived in the Emergency Department (ED). … hematoma following ACSS include (1) patient factors such as male sex, age over 65 years, low body mass index … The order and timing of subsequent interventions depends on the severity of presentation and surgeon … Even when properly prepared, however, the high stress of airway emergencies can lead to cognitive overload … The Vortex: a universal “high-acuity implementation tool” for emergency airway management.
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psnet.ahrq.gov/issue/healing-our-own-randomized-trial-assess-benefits-peer-support
May 19, 2021 - 2022
In situ simulation for adoption of new technology to improve sepsis care in rural emergency … February 15, 2023
A new index for obstetrics safety and quality of care: integrating
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - As her symptoms worsened, she contemplated returning to the emergency department (ED). … patients with CHF was associated with fewer hospital days and readmissions in the 6 months following the index … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Effectiveness of an organized follow-up system for elder patients released from the emergency department … Physicians, and Society for Academic Emergency Medicine.
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - The Case A 32-year-old woman with weight of 100.2 kg (body mass index of 39.1) with a history of gastroesophageal … It must also be noted that the last resort in the emergency airway algorithm is performing an emergency … All attempts to secure an airway in an emergency must be made, including performing a surgical airway … Surgical airway kits are part of the emergency medical equipment that should be available and checked … Call for help in an emergency and proceed down the emergency airway algorithm.
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - The Case
A five-year-old fully immunized girl was brought to the emergency department (ED) for an upper … Despite two emergency department (ED) visits in the days preceding her rapid
clinical decline, the patient … community-acquired pneumonia, with the degree of
hyponatremia thought to be correlated with pneumonia severity … Such complications
are often not suspected based on the physical examination alone; a high index of … Pneumonia severity in children: utility of procalcitonin in risk
stratification.
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - mortality from sepsis
4
Case Details (1)
• A five-year-old fully immunized girl was brought to the emergency … – Autopsy demonstrated bilateral pneumonia with right-sided empyema.
– Despite two emergency department … community-acquired
pneumonia, with the degree of hyponatremia thought to be correlated with pneumonia
severity … – Such complications are often not suspected based on the physical examination alone; a high
index … Pneumonia Severity in Children: Utility of Procalcitonin in Risk Stratification.
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - key populations or risk groups with some common shared patient characteristics (i.e., high body mass index … suspected difficult airways in patients undergoing general endotracheal anesthesia, (2) a high body mass index … Specifically, the team observed the number of adverse events in all patients with a body mass index at … 2024
Patient Safety Innovations
Suicide Prevention in an Emergency
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - ETT is kinked in the pharynx, which can be diagnosed either via bronchoscopy or by placing a gloved index … members of the surgical team during simulations to improve their performance during actual patient care emergencies … Good communication between team members is vital when diagnosing and managing an operative emergency, … Team participation in simulations of intraoperative emergencies can improve crisis management skills … Operating room crisis checklists and emergency manuals.
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - conjunction with screening, but it is so non-specific as to be more useful for prognostication and severity … calculator, APACHE II (Acute Physiology and Chronic Health Evaluation II), and the MPI (Mannheim Peritonitis Index … Predictors of mortality in patients with acute small-bowel perforation transferred to ICU after emergency … Emergency Laparotomy Audit (NELA). … Damage control surgery for abdominal emergencies.
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - complex abdomen
Discuss complications of abdominal access and management if injury is seen during the index … operation
The Case
A 49-year-old woman presented to the Emergency Department (ED) with abdominal … The patient had a history of morbid obesity (body mass index [BMI] 49); chronic pelvic pain; urinary … January 17, 2024
Prevalence, causes and severity of medication administration errors
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - The diameter index safety system prevents an oxygen hose from accidentally being connected to a nitrous … The pin index safety system (Figure 2) theoretically prevents a nitrous oxide cylinder from being mounted … Pin Index Safety System Source: Dondelinger RM. Compressed gas cylinders. … safety system, the pin index safety system and linked gas flow, as described earlier. … May 5, 2010
Leveraging artificial intelligence to reduce diagnostic errors in emergency
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - longer tracheostomy tubes, with proximal extensions, should be considered for patients with body mass index … tracheostomy tubes have relatively large resting cuff diameters, thus minimizing the frequency and severity … Tracheostomy emergencies. … November 16, 2022
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022
The effect of clinical experience on the error rate of emergency physicians
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - surgery, obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), obesity (body mass index … One day later, he returned to the hospital emergency department with severe nausea, vomiting, and abdominal
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - insurer in Massachusetts found that patients with retained foreign bodies were more likely to have had emergency … surgery, an unexpected change in surgical procedure, or a higher mean body-mass index, and were less … operation.( 2 ) In this study, failure to perform or complete counts generally occurred in the setting of emergency … September 23, 2020
Partnered pharmacist charting on admission in the general medical and emergency
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean … been admitted to the antepartum service or perhaps prescribed the medication based on her body mass index … many labor and delivery wards to improve team based medical care and reduce errors during obstetrical emergencies … As a result, appropriate actions and decisions can occur more quickly during emergencies. … in latent safety threats through regular interprofessional in situ simulation training of neonatal emergencies
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psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
February 01, 2004 - She directed him to the nearest emergency department, where his creatinine was found to be markedly elevated … "( 4 )
Nevertheless, maintaining a high index of suspicion for chronic urinary retention and renal … The American Urological Association symptom index for benign prostatic hyperplasia. … Hygiene Compliance
May 1, 2014
Optimizing Pediatric Patient Safety in the Emergency
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Case A 38-year-old female patient with a height of 65 inches (165 cm) and weight of 153 kg (body mass index … increasing in many countries as part of a global obesity pandemic. 1,2 Class 3 obesity, with body mass index … Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - The Case
A 48-year-old woman with a history of obesity (body mass index [BMI] of 32), but without any … Their assistance is invaluable for providing safe patient care when an unanticipated emergency arises … Anesthetic emergencies are not always predictable and anesthesia care providers must be prepared for … anesthesia technologists is necessary to support the care team in responding promptly and effectively to emergencies
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - The Case A 2-month-old full-term male infant was brought to the Pediatric Emergency Department (PED) … In this case, the emergency medicine clinicians were clearly concerned about the possibility of abuse … imaging only in asymptomatic children undergoing child abuse evaluation, such as the sibling of an index … March 27, 2024
Crowding in the Emergency Department: Challenges for the Care of … June 9, 2021
Racial and ethnic differences in emergency department diagnostic imaging
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - The Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department … EQUIPPED was designed to decrease the number of PIMs prescribed to older adults upon discharge from the emergency … to assist with identifying PIMs, including the AGS Beers Criteria®, the Medication Appropriateness Index … Emergency departments can also identify patients at high risk for overdose and are another key distribution … Increased naloxone prescribing rates were attained in a large, tertiary care academic emergency department