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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - hospital
course but was ultimately discharged to a rehabilitation facility with no major permanent injuries … a
cervical laceration that extends beyond the vagina into the peritoneal cavity or a vaginal wall injury … (12) Furthermore, the operative field may appear dry during the
procedure when the patient's blood pressure … is low, only to have significant bleeding later emerge when
severe hypertensive pressures return, after
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part1.html
March 01, 2020 - For example, only half of people with high blood pressure have it controlled. … Leading causes of morbidity and mortality include heart disease, cancer, unintentional injuries, stroke
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/osteoporosis-vibration-therapy_technical-brief.pdf
January 01, 2020 - Pharmacological interventions can result in adverse outcomes,
commonly minimal trauma atypical fractures … weight-bearing exercise, may also increase bone density18,19 and may be
safer than medication, but risk of injury … discontinuation in 10-15 percent of patients.59 Common adverse effects from
bisphosphonates include minimal trauma … Women were excluded from these studies if they had any number of conditions such as high
blood pressure … They may also experience other side effects while using the platform, such
as decreased blood pressure
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - 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/node/33764/psn-pdf
April 01, 2014 - Does this accelerate the pressure to think about safety more broadly in the ambulatory
environment and … That report called out the
fact that many physical injuries are happening in the workforce, as well … as psychological injury due to lack
of respect, bullying, fear, stress, and productivity pressures.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
November 30, 2013 - • Current clinical conditions contributing to transfer risk: use of oxygen, catheter or
ostomy, any pressure … and skin, injury (fall
related or not fall related), musculoskeletal, abnormal labs or anemia, fever … or skin issues
• Fall-related injury
• Non-fall-related injury
• Abnormal labs
• Fever/possible infection … disease
• Asthma
• Circulatory problems
• Hypertension
• Gastroenteritis
• Angina pectoris
• Falls/trauma … obstructive
pulmonary disease, asthma, circulatory problems, hypertension, gastroenteritis, angina,
falls/trauma
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/nursing-staff-shortages-rapid-research-appendix-c.xlsx
January 01, 2024 - Indicator
QI Quality improvement
RN registered nurse
SD Standard deviation
SOII Survey of Occupational Injuries … California's nurse-to-patient ratio law and occupational injury. … Hospital-acquired pressure ulcers decreased from 26 before the staffing change to 22 after the staffing … LOS also decreased with the addition of nurses for pressure ulcers and postoperative respiratory failure … Tarazi, 2020 Observational with comparison Policy: Medicaid expansion NR Hospitals under financial pressures
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - Her vital signs included: blood pressure 154/113 mmHg, heart rate 75 beats/minute, respiratory rate 16 … Despite high levels of ED crowding, there is mounting pressure to see more patients in less time and … Patients with dangerous medical conditions and traumatic injuries may present with normal or near-normal … Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review. … June 14, 2023
WebM&M Cases
Under Pressure: Delayed
-
www.uspreventiveservicestaskforce.org/uspstf/document/treatment-evidence-summary/gestational-diabetes-mellitus-screening-january-2014
May 28, 2013 - For other injury outcomes (that is, brachial plexus injury and clavicular fractures), results were inconsistent … Second, where reported, definitions of preeclampsia varied (for example, a blood pressure of 140/90 mm … apart, these criteria with laboratory measures indicative of preeclampsia, or an increase in blood pressure … because of heterogeneity
88
Cohort
2
515
−1.04 (−2.89 to 0.81) ‡
8
Maternal birth trauma … 1
1030
0.35 (0.01 to 8.45)
NA
Cohort
1
389
0.02 (0.00 to 0.22) †
NA
Birth trauma
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
January 01, 2019 - 51.9% in 2013 67.7% in 2017 -9.5 0.006
Surgical Safety Home health care patients whose surgical
wound … single measure that was not changing over time
examines long-stay nursing home patients who experience injuries … Ulcers Short-stay nursing home patients with new or
worsening pressure ulcers (MDS)
0.7% in 2013 … Ulcers High-risk, long-stay nursing home patients with
pressure ulcer (MDS)
5.3% in 2013 4.8% in … 2017 -2.1 0.018
Falls Long-stay nursing home patients experiencing
one or more falls with major injury
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effectivehealthcare.ahrq.gov/sites/default/files/functional-limitations-horizon-scan-high-impact-1306.pdf
June 01, 2013 - dehiscence, conjunctival erosion, retinal detachment,
inflammation, and hypotony (low intraocular pressure … manufacturer include optic nerve disease, central artery or vein
occlusion, history of retinal detachment or trauma … dehiscence, conjunctival erosion, retinal
detachment, inflammation, and hypotony (low intraocular pressure … several experts thought that besides providing psychological benefits,
this intervention might improve pressure … neuroassistive technology because it does not tire easily
and is generally spared in spinal cord injuries
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www.uspreventiveservicestaskforce.org/uspstf/document/draft-research-plan/behavioral-counseling-interventions-promote-healthy-diet-physical-activity-weight-loss-prevent-cardiovascular-disease-adults
May 18, 2023 - including increased symptoms of depression and anxiety, and body image concerns
Exercise-induced injury … Self-reported weight
Continuous measures of glucose, blood pressure, or lipid levels
Behavioral
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/alcohol-misuse-drug-therapy_executive.pdf
January 27, 2012 - , suicide, and fetal alcohol syndrome.9,17 Excessive
alcohol consumption is also a major factor in injury … fires, drowning, falls, homicide, suicide, motor vehicle
crashes, child maltreatment, and pedestrian injuries … variety of adverse
effects such as nausea, dizziness, flushing,
and changes in heart rate and blood
pressure … No other details on the cause or nature of
the accident were provided.41 That study also reported 1 injury … Alcohol-attributable fraction for injury in the
U.S. general population: data from the 2005 National
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/renal-artery-stenosis_surveillance.pdf
June 01, 2012 - angioplasty with stent placement on long-term clinical outcomes (at least 6 months),
including blood pressure … ; however, a
smaller decrease in diastolic blood pressure in the revascularization group was observed … medical therapy
“There was no significant between-
group difference in systolic blood
pressure; the … PTA+ stenting
Blood Pressure Control:
Cured, n (%): 0 vs. 4 (11.1%);
p<0.001
Improved, n (%): 33 … hematoma or
hemorrhage requiring hospitalization, 5
cases of clinically significant acute kidney
injury
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - On hospital day 2, the primary trauma surgery team ordered magnetic resonance imaging (MRI) of the brain … These studies, completed on hospital day 6, showed no evidence of traumatic or hypoxic brain injury and … no vertebral or ligamentous injury; the radiologist noted “minimal cervical spine epidural blood or … capturing data for quality metrics or responding to messages from patients through portals certainly add pressure … professional society educational efforts may be helpful in addressing this generational problem. 15 Pressure
-
psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Patient safety improvement requires both internal and external pressure to drive change. … and Berwick have noted, systemic nationwide patient safety improvements require, among other
things, pressure … kernicterus) associated with failure to identify and treat
hyperbilirubinemia in neonates
Stage 3 or 4 pressure … Sexual assault on a patient within or on the grounds of a health care facility
Death or significant injury
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psnet.ahrq.gov/web-mm/premature-extubation
May 25, 2011 - If there is no cuff leak, it suggests that laryngeal edema or another type of laryngeal injury has reduced … The ICU decided to implement a standardized protocol for positive pressure weaning trials, which also … mechanical ventilation: clinical outcome in patients randomized for a 30-min or 120-min trial with pressure … Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation.
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - With regulatory and financial pressures directed toward reducing hospital-acquired infections, attention … They include dislodgement due to trauma, urethral erosion (traumatic hypospadias due to pressure necrosis … occurs more frequently in men who perform intermittent catheterizations frequently (e.g., spinal cord injury … J Wound Ostomy Continence Nurs. 2007;24:655-661. [go to PubMed] 2. … Assist in healing of open sacral/perineal wound in incontinent patients.
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - The patient’s blood pressure was 174/101 mmHg, heart rate 126, respiratory rate 26, temperature 37.5 … The patient’s laboratory results were notable for acute kidney injury and metabolic acidosis, with an … only reported in 38 cases, but operator error, distraction, interruption, and emergency or after-hours pressure … December 4, 2024
WebM&M Cases
Under Pressure: Tracheostomy
-
www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … The toolkit draws on literature on best practices in pressure ulcer prevention and includes both validated … patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury