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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - They had taken her to the operating room, but she developed low blood pressure before the case and the … An evaluation of compliance with practice guidelines on interhospital trauma transfer. … An evaluation of compliance with practice guidelines on interhospital trauma transfer. … Injury. 2005;36:1051-1057. http://www.ncbi.nlm.nih.gov/pubmed/16098332
Warren J, Fromm RE Jr, Orr RA, … An evaluation of compliance with practice guidelines on interhospital trauma transfer.
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psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
January 01, 2015 - Over the next few minutes, the patient's blood pressure skyrocketed to 250/135 mm Hg. … contributors to error in the current case are situational and likely include organizational culture and social pressure … toxic cultures that inhibit communication and assertion of concerns and that exert deep and pervasive pressure … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - ], and worse long-term brain function [5]), it is worth thinking about
delirium as an "acute brain injury … " similar to other end-organ injuries (e.g., heart attack, acute kidney injury). … As with these other important end-organ injuries, delirium is a clinical event for which prevention and … spontaneous breathing trials (SBT, defined as turning the ventilator settings to
continuous positive airway pressure
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psnet.ahrq.gov/web-mm/wheres-feeding-tube
September 01, 2003 - Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury … Because of the injuries, he was unable to swallow and had to receive nutrition through a nasojejunal … Perforation
March 15, 2023
WebM&M Cases
Under Pressure … Post-Tracheostomy Care
May 29, 2024
WebM&M Cases
Under Pressure
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - About halfway through the procedure, the anesthesiologist noticed that the
patient's blood pressure … anesthesiologist administered a bolus of
intravenous fluids, but over the next few minutes the patient's blood pressure … The patient required transfusion of multiple units of blood, and
fortunately the injury was repaired … challenge occurred when the
anesthesiologist alerted the surgeon during the initial drop in blood pressure … Paige, MD
Professor of Clinical Surgery
Director of Wound Care
LSU Health New Orleans Health Sciences
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Two days prior to admission, the patient presented to the obstetrics clinic with blood pressures (BPs … marked increase in her plasma volume with resultant increase in her preload (increased left atrial pressure … orders for type and frequency of blood tests, fetal monitoring, and surveillance of symptoms and blood pressure … Criteria for E stablishing Severe Preeclampsia.* • Persistent blood pressure above 160/110 mm … Related Resources
WebM&M Cases
Uterine Artery Injury
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - Case & Commentary: Part 1 A 57-year-old male with T8 paraplegia from a remote gunshot wound, hypertension … as follows: General: Mild respiratory distress with audible wheezing Vitals: Blood pressure … In one study, 90% of patients expected their blood pressure to be measured and their heart, lungs, abdomen … One of us (G.R.T.) has seen a patient with spinal cord injury who was transferred from an outside hospital … Clinical assessment of central venous pressure in the critically ill.
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - The patient remained alert and cooperative until 2350H when her blood pressure fell to 90/58. … Nevertheless, every patient deserves to be provided with the best opportunity to survive an illness or injury … that permits all necessary interventions to be provided commensurate with the degree of illness or injury … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery Division of Trauma … 2022
WebM&M Cases
Errors in Managing an Open Wound
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - medicine can be found in the field of neurosurgery where many hospitals refuse to treat closed head injuries … because of liability concerns.( 13 ) In complex patients, vaginal delivery may increase the risk of injury … to the mother or fetus; injuries in this setting often lead to malpractice claims. … Are evidence-based practices associated with effective prevention of hospital-acquired pressure
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - with factitious disorder consciously and manipulatively (usually
surreptitiously) produce illness or injury … advocated by most experienced practitioners.20 Applying cricoid pressure compresses the esophagus and … this communication error because the foreign
body likely traversed the gastrointestinal tract without injury … Scand J
Trauma Resusc Emerg Med. 2021;29(1):64. [Free full text]
20. … The clinical use of cricoid pressure: first, do no harm. Anesth Analg.
2021;132(1):261-267.
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - reason for us to make sure, at least from Leapfrog's spot,
that there's a continued laser focus and pressure … We
graded every hospital for which there's adequate data on errors, accidents, and injuries. … Then hopefully they will go to the hospital and put some pressure on them to elevate the
priority of … How do I protect them from the errors and injuries that are rampant? What can I do better?
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Upon further evaluation, she was noted to have a rapid heart rate
and low blood pressure. … Several
hours later, the patient was noted to be lethargic with a low blood pressure. … While the inpatient care team discussed possible causes for her low blood pressure, the microbiology … Automated, electronic alerts for acute kidney injury: a single-
blind, parallel-group, randomised controlled
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - The patient ultimately regained a pulse but required two vasopressors
to maintain her blood pressure … Bedside cannulation of the central circulation for measurement of central
venous pressure and for vasopressor … The patient immediately
responded, with improved oxygenation and blood pressure. … radiograph provided reassurance that the central line was in the correct position without
evidence of lung injury … Relative value of central-venous-pressure monitoring and blood-volume measurement in the
management
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psnet.ahrq.gov/issue/policies-and-practices-related-role-board-certification-and-recertification-pediatricians
February 03, 2011 - September 29, 2017
Medical injuries among hospitalized children.
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - We monitored the blood pressures of home peritoneal dialysis patients. … We knew their trends and that some of them had typically higher blood pressures and some of them had … typically lower blood pressures, so we created individual thresholds. 1 , 3 , 4
Sarah Mossburg: It … Historically, these are acute problems that arise where there is illness or injury. … We knew there were hospital capacity problems and a lot of different pressures and stakeholders that
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - We monitored the blood pressures of home peritoneal dialysis patients. … We knew their trends and that some of them had typically higher blood pressures and some of them had … typically lower blood pressures, so we created individual thresholds. 1 , 3 , 4
Sarah Mossburg: It … Historically, these are acute problems that arise where there is illness or injury. … We knew there were hospital capacity problems and a lot of different pressures and stakeholders that
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - About halfway through the procedure, the anesthesiologist noticed that the patient's blood pressure was … anesthesiologist administered a bolus of intravenous fluids, but over the next few minutes the patient's blood pressure … The patient required transfusion of multiple units of blood, and fortunately the injury was repaired … first challenge occurred when the anesthesiologist alerted the surgeon during the initial drop in blood pressure … Paige, MD Professor of Clinical Surgery Director of Wound Care LSU Health New Orleans Health Sciences
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psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
July 01, 2017 - this area from personal acquaintance with physicians and understanding their narratives of how legal pressures … That caring relationship doesn't end when an injury occurs, particularly if the injury is our fault. … They reduce the underlying safety problems that can lead to injuries that lead to claims. … Then, we have a few cases in which EHR systems themselves have had problems that have led to injuries … May 20, 2015
Medical monitoring for pharmaceutical injuries: tort law for the public's
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - On physical
examination, his initial blood pressure was elevated at 192/100 mm Hg, but his heart rate … Bilateral upper-extremity blood pressures were equal. … oral
antacid/anesthetic combination) was given, and the patient reported symptom relief; his blood pressure … ECG interpretation: sinus tachycardia, with posterolateral injury
pattern.
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - The patient ultimately regained a pulse but required two vasopressors to maintain her blood pressure … Bedside cannulation of the central circulation for measurement of central venous pressure and for vasopressor … The patient immediately responded, with improved oxygenation and blood pressure. … radiograph provided reassurance that the central line was in the correct position without evidence of lung injury … Relative value of central-venous-pressure monitoring and blood-volume measurement in the management of