-
psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - However, if you believe that these kinds of schedules
actually prevent injuries due to medical errors … There has been pressure within the nursing
community to keep shifts limited because of data, going back
-
psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … Infusion
July 31, 2023
WebM&M Cases
Under Pressure
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/hospitals/nicupacket.pdf
December 01, 2013 - ■ Should have:
– Blood pressure checked at every visit. … diarrhea are at risk for zinc defciency and may need
supplementation:
– Poor growth, diarrhea, impaired wound … ■ BPD, even in the absence of overt brain injury, is a risk factor for neurodevelopmental delay. … – Bivona
■ Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures … – Gastric or esophageal trauma during placement.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket.pdf
December 01, 2013 - ■ Should have:
– Blood pressure checked at every visit. … are at risk for zinc deficiency and may need
supplementation:
– Poor growth, diarrhea, impaired wound … – Bivona
■ Cuffed: Indicated to prevent chronic aspiration, or when ventilating with high pressures … – Set suction pressure between 80-100 mmHg. … – Gastric or esophageal trauma during placement.
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hcup-us.ahrq.gov/db/nation/nis/APS-DRGs%20V23%20Definitions%20Manual.pdf
August 01, 2006 - 507 Full Burn W Graft or Inhal W/O Sign Trauma
508 Full Burn W/O Graft or Inhal W Sign Trauma
510 … Ventilation - < 96 Hours
9672 Continuous Mechanical Ventilation - 96+ Hours
9390 Continuous Positive Airway Pressure … 440 440 WOUND DEBRIDEMENTS FOR INJURIES
441 441 HAND PROCEDURES FOR INJURIES
442 442 OTHER O.R PROCEDURES … 444 444 TRAUMATIC INJURY AGE >17
445 444 TRAUMATIC INJURY AGE >17
446 446 TRAUMATIC INJURY AGE … ,POISON&TOXIC EFFECT DX
455 454 OTH INJURY,POISON&TOXIC EFFECT DX
461 461 O.R.
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hcup-us.ahrq.gov/reports/methods/2015-06.pdf
January 01, 2015 - delivered, with
or without mention of antepartum condition 229,733 183,562 79.9
66481: Other specified trauma … medical care, not
elsewhere classified 10,966 9,161 83.5
51851: Acute respiratory failure following trauma … and
surgery 30,445 24,998 82.1
5185: Pulmonary insufficiency following trauma and surgery 111,856 … pregnancy, childbirth, and the puerperium
740-759 Congenital anomalies
905-909 Late effects of injuries … subsequent fall
E919 Accident caused by machinery (Except E919.2)
E921 Accident caused by explosion of pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/implement/implement-facilitator-guide.pdf
May 01, 2017 - communication
breakdowns are identified as the primary root
cause of maternal and perinatal deaths and
injuries … Other root causes for maternal and perinatal
deaths and injuries are—
• Assessment,
• Leadership, … Example:
The nurse says to the doctor, “Doctor, the
patient’s blood pressure is dropping; it is
60
-
psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - However, if you believe that these kinds of schedules actually prevent injuries due to medical errors … There has been pressure within the nursing community to keep shifts limited because of data, going back … March 2, 2011
Extended work duration and the risk of self-reported percutaneous injuries
-
psnet.ahrq.gov/node/33713/psn-pdf
June 01, 2011 - While the team adjusted the table, it swung loose and the
patient fell to the floor but sustained no injury
-
psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - She was afebrile,
tachycardic (120 beats per minute), with a normal blood pressure (109/51) and excellent … ulceration or
necrosis, chronic gastric irritation leading to gastrointestinal bleeding from gastritis or pressure … approximately 30 to 35 cm allows repositioning of misplaced
tubes and can potentially prevent pulmonary injury
-
psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - My criteria for neuroimaging are that if someone has a history of head trauma or evidence of bruising … In the absence of any neurologic changes, head trauma, or fever where you think there could be herpes … " 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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
January 01, 2004 - Database for
Florida from 1996–99 (373,814 discharges at 188 hospitals) to examine whether
financial pressure … Shen (2003) examined the
effect of financial pressures on patient outcomes and found that financial … pressures adversely affect patient outcomes.7 That study used data from an earlier
period (1985–94), … The effect of financial pressure on the quality
of care in hospitals. … Excess length of stay, charges, and
mortality attributable to medical injuries during
hospitalization
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/007-ss-contact-precautions-fg.docx
April 01, 2025 - safety and safe injection practices to minimize the risk of infection transmission and needle stick injury … care equipment between patients – which in the pre-op area and PACU may mean equipment such as a blood pressure … Staff also reported feeling pressure to expedite transport by skipping steps in the contact precautions
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
January 01, 2004 - With disease, injury, or illness, the diagnosis is often obvious and may involve
no more than simple … Coercive pressures may drive a particular
agenda that is not congruent with good decisionmaking. … For example, team
pressures to lower door-to-needle times for thrombolytic therapy in the context of … affective error by changing systemic
features: decreased reliance on memory, minimization of time pressure … Minimize time pressures Provide adequate time for quality decisionmaking.
-
psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - disorder, commingled substance use disorder, neurocognitive impairment, history of
traumatic brain injury … Therefore, clinicians may face pressure due to non-
clinical factors (e.g., lack of inpatient psychiatric … .13 As illustrated
in this case, the risks of inadequate treatment involve suicide, self-inflicted injury
-
www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/obesity-in-children-and-adolescents-screening-2005
July 12, 2005 - Blood pressure was not improved, and in some cases increased blood pressure was a reason for discontinuation … stigmatization, binging or purging behaviors, eating disorders, suppressed growth, or exercise-induced injuries … Childhood risk factors for high adult blood pressure: the Muscatine Study. … Childhood predictors for high adult blood pressure. The Muscatine Study. … Alterations in anthropometric blood pressure and serum lipoprotein variables.
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
November 01, 2019 - His heart rate is
100 beats per minute, and his blood pressure is normal
at 121 over 75. … This could have prevented the development
of acute kidney injury or AKI, and additional laboratory … Using one of
the areas of harm, acute kidney injury from
unnecessary vancomycin, let’s consider how
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/glaucoma-treatment_disposition-comments.pdf
April 01, 2012 - In this study, intraocular pressure
reduction was similar between the groups. … Krupin T, Reviewer #3n
JM, Greenfield DS, et al; Low-Pressure Glaucoma Study Group. … Public
comment/
AAO-AGS
Results Key Question3b
It is important to remember that target intraocular pressures … Likewise,
the conclusion that use of MMC results in lower intraocular
pressures needs to be considered … with glaucoma includes
increased risk of nursing home admission, depression, falls and/or
accidents, injury
-
hcup-us.ahrq.gov/reports/methods/2019-01.pdf
January 01, 2019 - • ED visits for injuries. … ED utilization for injuries was reported by trauma level and by age,
sex, community income, urban-rural … PDI11 Reclosure of postoperative
abdominal wound dehiscence per
1,000 abdominopelvic-surgery
admissions … PSI14 Reclosure of postoperative
abdominal wound dehiscence per
1,000 abdominopelvic-surgery
admissions … PSI17 Birth trauma - injury to neonate per
1,000 live births
Consistent with the AHRQ PSI software
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/obesity-in-adults-interventions
September 18, 2018 - recommendations on screening for abnormal blood glucose levels and type 2 diabetes, screening for high blood pressure … Intermediate outcomes (eg, prevalence of high blood pressure or the metabolic syndrome, use of cardiovascular … potential harms of behavioral weight-loss interventions, including increased risk for fractures, serious injuries … Association of overweight with increased risk of coronary heart disease partly independent of blood pressure … Screening for high blood pressure in adults: U.S.