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Showing results for "pressure injuries".
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121. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60551/psn-pdf
     January 01, 2021 - The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836964/psn-pdf
     April 20, 2022 - The most common preventable events were medication events, pressure injuries, and healthcare-associated

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50775/psn-pdf
     January 01, 2021 - reports involved interunit/department/team transfers and the majority (69%) of incidents were related to pressure … injuries, falls, medication, and documentation errors.

124. Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare. | PSNet
     psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
     August 24, 2022 - Emerging Classic Assessment of nursing home reporting of major injury … Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare … This study compared falls with injury data self-reported by nursing homes against those identified in … Download Citation Related Resources From the Same Author(s) Accuracy of pressure … September 14, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

125. Using a learning system approach to improve safety for prone-position ventilation patients. | PSNet
     psnet.ahrq.gov/issue/using-learning-system-approach-improve-safety-prone-position-ventilation-patients
     January 10, 2024 - Issues identified included medical device-related pressure injuries and device dislodgement, concerns … March 7, 2018 Information flow during pediatric trauma care transitions: things falling … 2019 Work system barriers and facilitators in inpatient care transitions of pediatric trauma … May 18, 2022 Error reduction in trauma care: lessons from an anonymized, national, multicenter

126. The Magnetic Deflection | PSNet
     psnet.ahrq.gov/web-mm/magnetic-deflection
     November 18, 2016 - She was admitted to the stroke unit and received aggressive treatment to control her blood pressure. … This powerful attractive force can result in injury to a patient or health care worker from any of various … These include, among others: Direct trauma from the accelerating ferromagnetic object striking the patient … To this day, injuries continue to occur in MRI scanners around the globe from ferromagnetic objects being … modality—at times with serious, and even fatal, consequences.( 6-10 ) The only way to avoid such events and injuries

127. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet
     psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
     October 31, 2023 - wound. … Trauma-induced coagulopathy: what you need to know. … Vascular injury and complication in neurosurgical spine surgery. … Hetastarch during initial resuscitation from trauma. … J Trauma . 2011;70(5 Suppl):S19-S21. [ Available at ] Hahn RG.

128. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet
     psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
     March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause … reviews findings of the subsequent root cause analysis , which determined training weaknesses, time pressures … , and distractions within the team due to the chaotic nature of trauma care . … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60228/psn-pdf
     April 15, 2020 - the identified events resulted in a delay in care and 41% resulted in temporary harm (e.g., falls, pressure … injuries, skin tears, abrasions).

130. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
     psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
     November 27, 2019 - The Case A 65-year-old man presented to a Level III trauma center with bilateral lower extremity paralysis … The patient was then transferred to a Level I trauma center that could provide a higher level of care … that results in wide fluctuation of blood pressure. … The combination of a supraphysiologic blood pressure target and the patient’s altered blood pressure … ’s spinal cord injury.

131. Underreporting of quality measures and associated facility characteristics and racial disparities in US nursing home ratings. | PSNet
     psnet.ahrq.gov/issue/underreporting-quality-measures-and-associated-facility-characteristics-and-racial
     August 09, 2023 - and pressure ulcers ). … August 9, 2023 Accuracy of pressure ulcer events in US nursing home ratings. … August 24, 2022 Assessment of nursing home reporting of major injury falls for quality … September 14, 2022 Accuracy of pressure ulcer events in US nursing home ratings. … July 15, 2020 Assessment of nursing home reporting of major injury falls for quality

132. Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool. | PSNet
     psnet.ahrq.gov/issue/exploring-nursing-sensitive-events-home-healthcare-national-multicenter-cohort-study-using
     August 05, 2020 - The most common types of nursing-sensitive events were falls , pressure injuries, healthcare-associated … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure

133. ROI for a fall prevention intervention: invest a little, save a lot. | PSNet
     psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save-lot
     September 13, 2017 - Falls and falls with injury are significant sources of morbidity and mortality and can have substantial … This study showed  that after implementing the Fall TIPS program, falls and falls with injury decreased … November 3, 2021 Trauma resuscitation errors and computer-assisted decision support. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

134. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/840141/psn-pdf
     November 16, 2022 - reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure … injuries and healthcare-acquired infections.

135. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
     January 01, 2024 - were worse when supine, but nocturnal headaches can be the presenting sign of elevated intracranial pressure … keep patients awake at night should prompt repeat imaging given the concern for elevated intracranial pressure … which allows time for the brain to adapt to tissue displacement and modestly increased intracranial pressure … Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma. … Trauma Surg Acute Care Open. 2018;3(1):e000129.

136. A longitudinal study of a multifaceted intervention to reduce newborn falls while preserving rooming-in on a mother-baby unit. | PSNet
     psnet.ahrq.gov/issue/longitudinal-study-multifaceted-intervention-reduce-newborn-falls-while-preserving-rooming
     March 20, 2019 - implementation, the hospital achieved one year without any newborn falls and there were no fall-related injuries … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45251/psn-pdf
     August 24, 2016 - Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery … center, this news article describes how factors such as production pressure and insufficient assessment … advancing-patient-safety-cataract-surgery-betsy-lehman-center-expert-panel-report https://psnet.ahrq.gov/web-mm/production-pressures

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73389/psn-pdf
     June 16, 2021 - estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients- medical-and-surgical Some adverse events are sensitive to aspects of nursing care, including pressure … injuries, falls, hospital- acquired urinary tract infections, and medication administration errors.

139. Secured But Not Always Safe | PSNet
     psnet.ahrq.gov/web-mm/secured-not-always-safe
     October 01, 2015 - use have been reported.( 6 ) The most common complications include aspiration and unintended local trauma … with LMAs and high peak inspiratory pressures, allowing for inspired gases to insufflate the stomach … LMA use can also lead to injuries secondary to high cuff pressure and volume during prolonged procedures … These increased intra-cuff pressures can cause a significant damage to surrounding tissues. … the pyriform sinus, which is where the recurrent laryngeal nerve enters, rendering it vulnerable to injury

140. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
     psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
     September 27, 2023 - causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … manage potential foreign bodies, clinicians should have a low threshold for involving an experienced trauma … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery, Division of Trauma … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.