-
psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - which Brennan
and colleagues defined in the Harvard Medical Practice Study in New York State as “an injury … Thoracic Surgeons offers patient safety
indicators for adult cardiac surgery, such as deep sternal wound … injuries) and hospital acquired infections (CLABSI, CAUTI). … dehiscence, and obstetric trauma. … deaths due to health care-associated venous
thromboembolism, sepsis, or patient falls; in-hospital pressure
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psnet.ahrq.gov/issue/error-reduction-trauma-care-lessons-anonymized-national-multicenter-mortality-reporting
March 24, 2021 - J Trauma Acute Care Surg. 2022;92(3):473-480. doi:10.1097/ta.0000000000003485. … J Trauma Acute Care Surg . 2022; 92 (3) :473-480 . … J Trauma Acute Care Surg. 2022;92(3):473-480. doi:10.1097/ta.0000000000003485. … June 30, 2021
Zero preventable deaths after traumatic injury: an achievable goal. … More
Related Resources
WebM&M Cases
Under Pressure
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psnet.ahrq.gov/issue/factor-structure-and-construct-validity-hospital-survey-patient-safety-culture-using
June 29, 2022 - May 8, 2017
A randomized trial of a multifactorial strategy to prevent serious fall injuries … February 22, 2023
Barriers and facilitators to reporting medical device-related pressure
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psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
September 23, 2020 - March 5, 2025
A randomized trial of a multifactorial strategy to prevent serious fall injuries … May 29, 2024
WebM&M Cases
Under Pressure: Delayed Diagnosis
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - The required
insufflation leads to an increase in peak inspiratory pressures, and this increase is more … pronounced during
dilation as the balloon pressure increases tracheal stress. … Patient death or serious injury associated
with intravascular air embolism that occurs while being cared … vessel may be exposed due to underlying disease (e.g., ulcers,
mucosal inflammation), scope-induced injury … Technical steps like using appropriate monitoring, minimizing insufflation and dilation pressures to
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psnet.ahrq.gov/node/860380/psn-pdf
January 10, 2024 - The authors attributed low
positive predictive value (PPV) in three of the PSIs (pressure injury, falls
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psnet.ahrq.gov/issue/incidence-and-nature-hospital-adverse-events-systematic-review
March 24, 2011 - 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/846169/psn-pdf
March 15, 2023 - young patients because their strong
chest wall muscles can create much higher negative intrathoracic pressures … Succinylcholine is
contraindicated in patients with stroke, spinal cord injury, burns, or myotonic dystrophy … inadequate resources such as the broken drug refrigerator otherwise could have led to irreversible injury … Risk of respiratory complications and wound infection in
patients undergoing ambulatory surgery: smokers … Negative-pressure pulmonary edema. Chest.
2016;150(4):927-933. [Available at]
14.
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - chest wall muscles can create much higher negative intrathoracic pressures than those of elderly patients … Succinylcholine is contraindicated in patients with stroke, spinal cord injury, burns, or myotonic dystrophy … inadequate resources such as the broken drug refrigerator otherwise could have led to irreversible injury … Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers … Negative-pressure pulmonary edema.
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psnet.ahrq.gov/node/74864/psn-pdf
February 23, 2022 - patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
https://psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence
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psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
July 10, 2024 - September 27, 2016
Towards international consensus on patient harm: perspectives on pressure … injury policy. … August 7, 2019
Medical device-related pressure ulcers: a systematic review and meta-analysis
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psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review
October 08, 2016 - The authors explore areas of impact, including patient satisfaction, falls , and hospital-acquired pressure … From the Same Author(s)
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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psnet.ahrq.gov/node/49559/psn-pdf
April 01, 2008 - Multiple therapies were initiated to reduce the intracranial pressure and swelling, including intubation … The "Lund protocol," derived in patients with elevated ICP in the setting of head trauma, assumes
that … Continuous recording and control of ventricular fluid pressure in neurosurgical practice. … Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am. 1995;6:761-
773. … Hyperventilation in head injury: a review. Chest.
2005;127:1812-1827. [go to PubMed]
5.
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - improved
functional independence at 4 and 12 months.(12-14)
Hip fracture is a common and serious injury … , which in turn increases the risk of delirium, thromboembolism, pneumonia,
pressure ulcers, and significant … Injury. 2018;49:1458-1460. [go to
PubMed]
2. Cummings SR, Black DM, Rubin SM. … J Orthop Trauma.
2006;20:172-180. … J Orthop Trauma. 2014;28:e49-e55.
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psnet.ahrq.gov/node/49410/psn-pdf
July 01, 2003 - had heard of the availability of topical skin adhesive that can be used in place of sutures to
close wounds … An
ophthalmologist evaluated the child the next day, and fortunately, there was no permanent injury. … Proper use of tissue adhesives involves choosing appropriate wounds, as well as patients, for the
procedure … Prior to applying the product,
hemostasis must be achieved with either pressure or topical application … Tissue adhesives in wound care. Hamilton: B.C. Decker Inc.; 2003.
7.
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psnet.ahrq.gov/issue/using-community-detection-techniques-identify-themes-covid-19-related-patient-safety-event
July 29, 2020 - (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors , pressure … June 16, 2021
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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psnet.ahrq.gov/issue/technical-rationality-and-decentring-patients-and-care-delivery-critique-unavoidable-context
October 08, 2016 - From the Same Author(s)
Towards international consensus on patient harm: perspectives on pressure … injury policy. … June 14, 2019
Medical device-related pressure ulcers: a systematic review and meta-analysis
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psnet.ahrq.gov/issue/nurse-burnout-syndrome-and-work-environment-impact-patient-safety-grade
August 04, 2021 - August 19, 2020
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury
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psnet.ahrq.gov/issue/multimethod-study-large-scale-programme-improve-patient-safety-using-harm-free-care-approach
January 23, 2019 - improvement project in the United Kingdom to address four patient safety issues: venous thromboembolism , pressure … August 5, 2020
Towards international consensus on patient harm: perspectives on pressure … injury policy.
-
psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - which Brennan and colleagues defined in the Harvard Medical Practice Study in New York State as “an injury … Thoracic Surgeons offers patient safety indicators for adult cardiac surgery, such as deep sternal wound … injuries) and hospital acquired infections (CLABSI, CAUTI). … dehiscence, and obstetric trauma. … deaths due to health care-associated venous thromboembolism, sepsis, or patient falls; in-hospital pressure