-
psnet.ahrq.gov/node/36178/psn-pdf
September 30, 2010 - The cases resulted in significant harm: 23% of the patients died, and 65% suffered
disabling injuries
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psnet.ahrq.gov/node/46375/psn-pdf
November 29, 2017 - patient-education-prevent-falls-among-older-hospital-inpatients-randomized-controlled-trial
https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities
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psnet.ahrq.gov/issue/hospital-safety-records-ceo-pay-increasingly-linked
March 03, 2010 - Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma … March 8, 2015
More than 750 hospitals face Medicare crackdown on patient injuries.
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psnet.ahrq.gov/node/36813/psn-pdf
March 24, 2011 - annually are due to preventable adverse
events in the ambulatory setting, with 10% resulting in permanent injuries
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psnet.ahrq.gov/issue/target-achieve-zero-preventable-trauma-deaths-through-quality-improvement
March 03, 2011 - A Target to Achieve Zero Preventable Trauma Deaths Through Quality Improvement. … 2014
Beating the weekend trend: increased mortality in older adult traumatic brain injury … , 2012
Incidence and predictors of opioid prescription at discharge after traumatic injury … August 5, 2020
Undertriage of elderly trauma patients to state-designated trauma centers … December 21, 2014
WebM&M Cases
Missing the Point—Eye Injury
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psnet.ahrq.gov/node/60256/psn-pdf
April 22, 2020 - A critical review: moral injury in nurses in the aftermath of
a patient safety incident. … A critical review: moral injury in nurses in the aftermath of a patient safety
incident. … https://psnet.ahrq.gov/issue/critical-review-moral-injury-nurses-aftermath-patient-safety-incident
This … The authors describe ‘moral injury’ as an experience violating deeply held moral values and
beliefs, … Moral injury
symptoms identified in this review included guilt, shame, spiritual-existential crisis,
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - to the skin and soft tissues, and ischemic injury resulting in digital necrosis. … Arguably the most severe complication of digital tourniquets, ischemic injuries, have two principal causes … phenomenon and scleroderma, but it is not clear if these have been used or are effective in tourniquet trauma … J Orthop Trauma. 2010 Jun;24(6):387–8.
Smith IM, Austin OMB, Knight SL. … J Trauma. 2006 Dec;61(6):1415–8.
Lahham S, Tu K, Ni M, Tran V, Lotfipour S, Anderson CL, et al.
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psnet.ahrq.gov/node/73217/psn-pdf
May 05, 2021 - Assessing patients 2019 experiences with medical injury
reconciliation processes: item generation for … Assessing patients 2019 experiences with medical injury
reconciliation processes: item generation for … https://psnet.ahrq.gov/issue/assessing-patients-2019-experiences-medical-injury-reconciliation-processes … This article describes the
development and pilot testing of the Medical Injury Reconciliation Experiences … addresses patient and/or family perceptions of communications with healthcare providers
after the injury
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psnet.ahrq.gov/node/844052/psn-pdf
July 01, 2012 - medication administration
errors) versus other contexts, such as individual harms (e.g., sports-related injuries
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psnet.ahrq.gov/node/46009/psn-pdf
September 13, 2017 - long-term-outcomes-medication-intervention-using-screening-tool-older-persons-potentially
https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities
-
psnet.ahrq.gov/node/37467/psn-pdf
January 01, 2009 - The majority of events led primarily to temporary physical injuries.
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Patient death or serious injury … age, who is unable to make decisions, to other than
an authorized person
Patient death or serious injury … , while being cared for in
a healthcare setting
Care management events
Patient death or serious injury … associated with unsafe administration of blood products
Maternal death or serious injury associated … of a neonate associated with labor or delivery in a low-risk pregnancy
Patient death or serious injury
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psnet.ahrq.gov/node/50862/psn-pdf
February 05, 2020 - Assessment of nursing home reporting of major injury
falls for quality measurement on Nursing Home Compare … Assessment of nursing home reporting of major injury falls for quality
measurement on nursing home compare … https://psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement … This study compared falls with injury data self-reported by nursing
homes against those identified in … Medicare claims data and found that falls with injury were substantially
underreported by nursing homes
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psnet.ahrq.gov/node/73289/psn-pdf
May 19, 2021 - Clinical characteristics and short-term outcomes of acute
kidney injury missed diagnosis in older patients … Clinical characteristics and short-term outcomes of acute kidney injury missed
diagnosis in older patients … https://psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed … cohort of 107
patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury … https://psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
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psnet.ahrq.gov/node/855106/psn-pdf
November 08, 2023 - Home Health Agencies Failed To Report Over Half of Falls
With Major Injury and Hospitalization Among … https://psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half-falls-major-injury-and-
hospitalization-among … This report examines the incidence of Medicare home health
patients experiencing falls with major injury … https://psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half-falls-major-injury-and-hospitalization-among … https://psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half-falls-major-injury-and-hospitalization-among
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psnet.ahrq.gov/node/836761/psn-pdf
March 16, 2022 - Complexity bias in the prevention of iatrogenic injury:
why specific harms may inhibit performance. … Complexity bias in the prevention of iatrogenic injury: why
specific harms may inhibit performance. … https://psnet.ahrq.gov/issue/complexity-bias-prevention-iatrogenic-injury-why-specific-harms-may-inhibit … https://psnet.ahrq.gov/issue/complexity-bias-prevention-iatrogenic-injury-why-specific-harms-may-inhibit-performance … https://psnet.ahrq.gov/issue/complexity-bias-prevention-iatrogenic-injury-why-specific-harms-may-inhibit-performance
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psnet.ahrq.gov/node/38203/psn-pdf
November 05, 2008 - Addressing prehospital patient safety using the science
of injury prevention and control. … Addressing prehospital patient safety using the science of injury
prevention and control. … https://psnet.ahrq.gov/issue/addressing-prehospital-patient-safety-using-science-injury-prevention-and … control
This commentary discusses patient safety in emergency medical services (EMS) and illustrates how injury … https://psnet.ahrq.gov/issue/addressing-prehospital-patient-safety-using-science-injury-prevention-and-control
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psnet.ahrq.gov/node/35652/psn-pdf
June 25, 2010 - No-fault compensation in New Zealand: harmonizing
injury compensation, provider accountability, and … No-fault compensation in New Zealand: harmonizing injury compensation, provider
accountability, and … https://psnet.ahrq.gov/issue/no-fault-compensation-new-zealand-harmonizing-injury-compensation-
provider-accountability-and … The authors provide context for the genesis of New Zealand's no-fault process for patient injury
compensation … https://psnet.ahrq.gov/issue/no-fault-compensation-new-zealand-harmonizing-injury-compensation-provider-accountability-and
-
psnet.ahrq.gov/node/73657/psn-pdf
September 01, 2021 - Communication failures contributing to patient injury in
anaesthesia malpractice claims. … Communication failures contributing to patient injury in
anaesthesia malpractice claims. … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims … https://psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims
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psnet.ahrq.gov/node/38589/psn-pdf
May 04, 2010 - Framing family conversation after early diagnosis of
iatrogenic injury and incidental findings. … Framing family conversation after early diagnosis of iatrogenic
injury and incidental findings. … https://psnet.ahrq.gov/issue/framing-family-conversation-after-early-diagnosis-iatrogenic-injury-and- … cholecystectomies, surgical residents felt ill-trained to disclose both complications
(common bile duct injury … https://psnet.ahrq.gov/issue/framing-family-conversation-after-early-diagnosis-iatrogenic-injury-and-incidental-findings