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1101. Getting the Diagnosis Both Right and Wrong | PSNet
      psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
      May 29, 2024 - Laboratory tests showed acute kidney injury with markedly elevated levels of potassium, phosphate, and … The patient's blood pressure improved with fluids. … Six hours after admission, the patient's blood pressure started to drop, requiring further intravenous … Despite aggressive measures to maintain her circulation, blood pressures further dropped, and a code

1102. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49677/psn-pdf
      February 01, 2013 - history of hypertension, psychiatric illness, and a previous suicide attempt overdosed on her blood pressure … The ED team thought this was likely due to severe hypotension (her systolic blood pressure was around … The possibilities for harm are numerous and include accidental trauma to non-venous structures (arteries … , lung, nerve, visceral organs); bleeding (hematoma, hemothorax, or hemorrhage); operator injury (needle … wire, bloodstream infections, sheared catheter, dysrhythmias, thrombosis, through-and-through vessel trauma

1103. Do Transient Working Conditions Trigger Medical Errors? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
      January 01, 2003 - .6, 10–12 Injuries to workers result from a causal chain of events involving both latent and immediate … Indeed, many risk factors for injury that have been studied in case-crossover studies of injury are … circumstances may be the result of other working conditions, such as a hectic work environment, time pressures … Case-crossover studies of occupational trauma: methodological caveats. … Injury Prevention 2001;7:Supplement 38–42.

1104. Transition to Nowhere | PSNet
      psnet.ahrq.gov/web-mm/transition-nowhere
      March 21, 2009 - dystrophy, hypertension, and chronic kidney disease was admitted to the hospital with anuric acute kidney injury … transition management team could conduct a home visit or a telemedicine visit utilizing self-taken blood pressure … More Related Resources WebM&M Cases Under Pressure

1105. AHRQ Views: Celebrating the 40th Anniversary of the U.S. Preventive Services Task Force | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsletters/e-newsletter/920.html
      July 01, 2024 - 36 states from AHRQ’s Healthcare Cost and Utilization Project focusing on adverse outcomes such as pressure … Epidemiology and clinical outcomes of community-acquired acute kidney injury in the emergency department

1106. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
      April 29, 2020 - On arrival, she was in septic shock with systolic blood pressure in the 80’s. … Common examples include pneumonia, Clostridium difficile infection, pressure injuries, delirium, and … diarrhea in an incontinent patient with skin breakdown on the “backside” should have raised an alarm, as wound … The use of a video visit for wound care is possible as skin and wound tissue can be adequately evaluated … Wesley Valdes, DO Telehealth and Wound Specialist Sacramento, CA wesley.valdes@gmail.com Garth

1107. Don't Dismiss the Dangerous: Obstetric Hemorrhage | PSNet
      psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
      August 21, 2024 - hospital course but was ultimately discharged to a rehabilitation facility with no major permanent injuries … from 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

1108. Healthcare Safety Competencies Affinity Group Environmental Scan (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/healthcare-safety-competency-environmental-scan.pdf
      March 27, 2025 - including central line-associated bloodstream infections, ventilator-associated events, hospital-acquired pressure … injuries, patient falls, and catheter-associated urinary tract infections during the COVID-19 pandemic … Bureau of Labor Statistics, in 2018, healthcare workers accounted for 73% of all nonfatal workplace injuries … Safety Science- Adjacent • Workload Management • Burnout • Worker Safety • Fatigue • Moral Injury … The Human Experience • Burnout • Co-Design • Fatigue • Improving Access to Care • Moral Injury

1109. Microsoft Word - NHQRDR9_HCUP Methods Report_final.doc (pdf file)
      hcup-us.ahrq.gov/reports/methods/2011_06.pdf
      January 01, 2011 - E Codes: Another issue relates to external cause-of-injury reporting. … data to help identify complications of care or to exclude cases (e.g., poisonings, self-inflicted injury … , delirium and other psychoses, anoxic brain injury; patients with metastatic cancer, lymphoid malignancy … , bone malignancy, and self-inflicted injury; admissions for diseases and disorders of the musculoskeletal … PSI 17 Birth trauma - injury to neonate per 1,000 live births (excluding preterm and osteogenesis imperfecta

1110. Wheeled Mobility (Wheelchair) Service Delivery (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/wheelchair-service_technical-brief.pdf
      January 01, 2012 - , pressure sores, falls, and accidents), equipment abandonment, and underutilization.9-13 Wheeled … or trauma who will require a wheelchair for mobility beyond a period of rehabilitation).15 The Brief … Adverse events/harms/safety issues (i.e., pressure sores, injuries, need for repairs, need for replacement … Wheelchair related injuries treated in US emergency departments. … problems with wheelchair Wheelchair functionality, seating comfort, pain, occupational performance, pressure

1111. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49444/psn-pdf
      May 01, 2004 - Both doctors and nurses recounted professional requests for health care "favors" include taking blood pressures … In this case, the resident may not have been fully competent to perform the exam (resulting in injury … Additionally, failing to include nursing in procedures exposes patients to risks of injury related to

1112. Evidence Summary: Prediabetes and Type 2 Diabetes: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary/screening-for-prediabetes-and-type-2-diabetes
      August 24, 2021 - , and diastolic blood pressure (pooled weighted mean difference, −1.7 mm Hg [95% CI, −2.6 to −0.8] and … by targeting pressures less than 150/85 mm Hg vs less tight control targeting pressures less than 180 … The state of US Health, 1990-2016: burden of diseases, injuries, and risk factors among US states. … Long-term follow-up after tight control of blood pressure in type 2 diabetes. … ; National High Blood Pressure Education Program Coordinating Committee.

1113. Near Miss with Bedside Medications | PSNet
      psnet.ahrq.gov/web-mm/near-miss-bedside-medications
      February 01, 2006 - On further history, he revealed that he had recently increased his beta-blocker, a blood pressure medication … In case of injury, there may have been no attempt at recovery, or the attempts may have been unsuccessful … From the Same Author(s) Perspective Removing Insult from Injury—Disclosing … 2004 A randomized trial of a multifactorial strategy to prevent serious fall injuries

1114. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - complications and the time period for ascertainment.11,14,17,18 – The most common complications are wound … Liver injury during PEG tube placement: report of two cases. … Trauma Surg Acute Care Open. 2022;7(1):e000800. [Free full text] 45. … Trauma transitional care coordination: a mature system at work. … J Trauma Acute Care Surg. 2018;84(5):711-717. [Available at 48.

1115. In Conversation With… Tejal K. Gandhi, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
      February 26, 2025 - 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.

1116. Saved by ECMO | PSNet
      psnet.ahrq.gov/web-mm/saved-ecmo
      May 05, 2017 - Epidural anesthesia is often preferred as it avoids the increase in PVR that accompanies positive pressure … inability of external compressions to generate enough force to overcome elevated pulmonary arterial pressures … Related Resources WebM&M Cases Uterine Artery Injury

1117. S50 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/s50.pdf
      October 01, 2007 - Practice-Based Evidence for Clinical Practice Improvement in Long-term Care The National Pressure Ulcer … No resident started with a pressure ulcer, but 29% of residents developed one by the end of the 12-week … Interventions identified by regression analyses to be associated with decreased likelihood of pressure … Measuring medical complexity during inpatient rehabilitation after traumatic brain injury. … The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents

1118. Practice and Quality Improvement | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-improvement.html
      May 01, 2024 - Appendix D: Grant Summaries P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury … would improve the use of a hypertension focused clinical decision support to effectively improve blood pressure … support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure … program that supports patients discharged from the hospital to home after an episode of acute kidney injury … health improvement project in 60 primary care clinics throughout Alabama to improve rates of blood pressure

1119. Chronic-urinary-retention-protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/chronic-urinary-retention_research-protocol.pdf
      November 19, 2012 - Examples of neurologic causes include spinal cord injury (SCI), stroke, multiple sclerosis (MS), and … diabetes mellitus.3 Other causes include Fowler’s syndrome in women, trauma, postoperative complications … In men it may also be important to determine whether the retention is high-pressure or low-pressure … retention (detrusor pressure at the end of micturition) as this may affect treatment decisions.4 However … Bladder management for adults with spinal cord Injury: A clinical practice guideline for health-care

1120. EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs4-infection-prevention-mdro-protocol.pdf
      July 01, 2023 - workers, exposure to antibiotics (with their effects on the patient microbiome as well as evolutionary pressure … interventions • Education-only interventions • Respiratory precautions (droplet, airborne, negative pressure … isolation/satisfaction o Noninfectious adverse healthcare- associated outcomes (hospital- acquired pressure … injuries, inpatient falls) • Clinical outcomes specifically for: o Central-line associated bloodstream