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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
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psnet.ahrq.gov/node/850159/psn-pdf
June 07, 2023 - characteristics and reporting patterns
for two measures of nursing home care quality (falls with major injury … and pressure ulcers). … does-nursing-home-compare-reflect-patient-safety-nursing-homes
https://psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 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.
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - did not recover spontaneous circulation for more than 30 minutes and sustained severe anoxic
brain injury … For example, the trauma
surgery service did not routinely perform a clamping trial before chest tube … most common complication),
recurrent pneumothorax, infection (including empyema), organ or vessel injury … Complications following thoracic trauma managed with tube
thoracostomy. Injury. 2012;43:46-50. … Complications of tube thoracostomy for
acute trauma. Am J Surg. 1980;140:738-741.
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psnet.ahrq.gov/issue/safety-climate-associated-adverse-events-nursing-homes-national-va-study
September 08, 2021 - The survey found that supervisor commitment to safety was associated with lower rates of major injuries … from falls and catheter use, and that environmental safety was associated with lower rates of pressure … ulcers, major injuries from falls, and catheter use.
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psnet.ahrq.gov/issue/effects-harm-events-30-day-readmission-surgical-patients
July 31, 2019 - The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%) … Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … injuries.
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psnet.ahrq.gov/issue/innovative-mobile-approach-patient-safety-services-case-taiwan-health-care-provider
September 27, 2017 - Citation
Related Resources From the Same Author(s)
Surgeon commitment to trauma … care decreases missed injuries. … June 15, 2012
System approach to prevent common bile duct injury and enhance performance … August 30, 2023
Interactive effects of nurse-experienced time pressure and burnout on
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psnet.ahrq.gov/node/837890/psn-pdf
August 24, 2022 - Accuracy of pressure ulcer events in US nursing home
ratings. … Accuracy of pressure ulcer events in US nursing home ratings. … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings
All nursing homes … This study compared seven years of
self-reported pressure ulcer data with claims-based data for pressure … does-nursing-home-compare-reflect-patient-safety-nursing-homes
https://psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - healing.2
17
17
General Approach to Wounds (4)
Eliciting the mechanism of injury will identify factors … the possibility of injury to deeper structures causing neurovascular injuries, fractures, or, for the … , arterial injury, open fracture, and foreign material.4,5
19
19
General Approach to Wounds (6) … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.
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psnet.ahrq.gov/issue/social-capital-and-knowledge-sharing-effects-patient-safety
September 15, 2011 - Related Resources From the Same Author(s)
System approach to prevent common bile duct injury … September 15, 2011
Surgeon commitment to trauma care decreases missed injuries. … June 15, 2012
Interactive effects of nurse-experienced time pressure and burnout on patient … January 9, 2011
The culture of a trauma team in relation to human factors.
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - The surgery was uncomplicated—her blood pressures intraoperatively were within 20% of her
baseline, … CRAO caused by globe compression is usually associated with
periorbital trauma (e.g., bruising, proptosis … with other signs of periorbital trauma. … Eye injuries after nonocular surgery. A study of
60,965 anesthetics from 1988 to 1992. … Injuries to the visual system and other sense organs. In: Benumof J, Saidman L,
eds.
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psnet.ahrq.gov/node/39545/psn-pdf
May 19, 2010 - Surgical robot examined in injuries.
May 19, 2010
Carreyrou J. … https://psnet.ahrq.gov/issue/surgical-robot-examined-injuries
This newspaper article discusses complications … explains that such
errors may have been exacerbated by inadequate clinician training and production pressures … https://psnet.ahrq.gov/issue/surgical-robot-examined-injuries
https://psnet.ahrq.gov//#productionpressure
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psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - Commonly used agents that cause severe extravasation injuries include antineoplastic, inotropic, or osmotically … Use to Promote Wound Healing In contrast, the wound healing literature generally supports the use … Treating chronic and acute wounds with warming: review of the science and practice implications. … Local heat increases blood flow and oxygen tension in wounds. Arch Surg. 1987;122:221-225. … March 5, 2025
WebM&M Cases
Under Pressure: Tracheostomy
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psnet.ahrq.gov/node/40507/psn-pdf
June 08, 2011 - From research to practice: factors affecting
implementation of prospective targeted injury-detection … From research to practice: factors affecting implementation of
prospective targeted injury-detection … https://psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury … five hospitals faced in implementing new systems for prospective detection
of adverse drug events and pressure … https://psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
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psnet.ahrq.gov/issue/instruments-and-warning-signs-identifying-and-evaluating-frequency-adverse-events
July 20, 2022 - Common adverse events impacting this population include adverse drug events, delirium , malnutrition, pressure … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - care hospitals, including the ability to care for patients requiring
mechanical ventilation, complex wound … Inpatient rehabilitation facilities (IRFs) care for patients recovering from surgery, trauma, or an … evaluation by a physician but do require
services such as intensive nursing, physical therapy, or wound … injuries) during their
stay, half of which were preventable. … injuries, and falls).
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psnet.ahrq.gov/issue/applying-hfmea-prevent-chemotherapy-errors
September 27, 2017 - Citation
Related Resources From the Same Author(s)
Surgeon commitment to trauma … care decreases missed injuries. … March 9, 2009
System approach to prevent common bile duct injury and enhance performance … May 22, 2013
Interactive effects of nurse-experienced time pressure and burnout on patient
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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.
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 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. [ Free full text ] Borst J, Godat LN, Berndtson AE,
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psnet.ahrq.gov/issue/comprehensive-program-reduce-rates-hospital-acquired-pressure-ulcers-system-community
May 12, 2021 - Study
A comprehensive program to reduce rates of hospital-acquired pressure ulcers … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … This implementation study sought to reduce incidence of pressure ulcers in hospitalized patients using … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … injury policy.