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1321. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet
      psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
      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 … My criteria for neuroimaging are that if someone has a history of head trauma or evidence of bruising

1322. Advances in Patient Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/reports/advances/index.html
      July 01, 2022 - Reige Surveillance Detection of Inpatient Health Care Associated Injuries: Comparing Two ICD-9-CM … Song, Tracey Pritchett Developing a Veterans Health Administration (VHA) Serious Injury Surveillance … Jaser, Nancy Safer, Paul Davern Medical Injury Identification Using Hospital Discharge Data (   PDF … Nozick Clinical Informatics and Its Usefulness for Assessing Risk and Preventing Falls and Pressure

1323. Final Progress Report: Connected Emergency Care (CEC) Patient Safety Learning Lab (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/hinson-levin-report.pdf
      January 01, 2025 - compounded in the emergency department (ED) by a hazardous decision-making environment fraught with time pressure … data-driven studies of infectious disease diagnostics performance,9,10 in-depth study of acute kidney injury … Renal outcomes following intravenous contrast administration in patients with acute kidney injury: a … Optimal Acute Kidney Injury Algorithm for Detecting Acute Kidney Injury at Emergency Department Presentation … Epidemiology and Clinical Outcomes of Community-Acquired Acute Kidney Injury in the Emergency Department

1324. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
      January 01, 2023 - by ambulance to a tertiary Emergency Department (ED) from a referring hospital due to a left leg injury … left hip flexed with significant tenderness on examination, but there were no other obvious signs of trauma … during a diagnostic or therapeutic procedure.”4,5 • Sedation can also ameliorate the psychological trauma … Patients often require assistance in maintaining a patent airway, and positive pressure ventilation … • Blood pressure should be measured frequently, and the electrocardiogram, heart rate, respiratory

1325. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy | PSNet
      psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
      July 08, 2022 - The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve … Latex is essential to these plants to heal surface injuries and create immune responses against invading … Thus, unexplained hypotension, tachycardia, and high airway pressure for adequate ventilation (due to … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

1326. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
      June 01, 2005 - a particular patient safety intervention is going to save large numbers of lives or reduce serious injuries … intervention, they referred to any event that resulted in the emergency team being called—low blood pressure … the error caught by their regular physician, others would experience asymptomatic reduction in blood pressure … July 14, 2010 Measurable outcomes of quality improvement in the trauma intensive care

1327. In Conversation With… Vineet Chopra, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
      February 28, 2024 - lines, you don't have to go anywhere near the great vessels of the neck or the chest, so you avoid injury … You avoid injury to the lung—that dreaded complication of pneumothorax. … You just put pressure at that site in the arm and compress the vessel against the underlying humerus. … Think about it: when you insert a PICC, your needle causes endothelial injury, in a patient that's hypercoaguable

1328. Disposition of Comments for Chronic Urinary Retention: Comparative Effectiveness and Harms of Treatments (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/chronic-urinary-retention_disposition-comments.pdf
      September 15, 2014 - acontractile detrusor secondary to cauda equine or peripheral nerve injury) It is more appropriate … In these cases, the primary goals of therapy are to reduce storage pressures (treat detrusor overactivity … The whole idea behind using botulinum toxin is to reduce storage pressures and reduce incontinence. … The Cruz study enrolled “patients with multiple sclerosis (MS; n = 154) or spinal cord injury (SCI; … to under active detrusor (failed contractility due to obstruction leading to CUR and measured by pressure

1329. Spinal Epidural Abscess | PSNet
      psnet.ahrq.gov/web-mm/spinal-epidural-abscess
      November 13, 2019 - The most common risk factors for SEA are diabetes mellitus, intravenous drug use, trauma, and alcohol … Yi Lu, MD, PhD Director, Neurosurgical Trauma Co-director, Adult Deformity and Scoliosis Surgery Assistant … March 1, 2005 WebM&M Cases Missing the Point—Eye Injury … More Related Resources WebM&M Cases Under Pressure … Pitfalls February 1, 2010 WebM&M Cases Missing Trauma

1330. Emergency Nurses Association content and transcript (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ena-slides.pdf
      September 01, 2015 - Need for resources • What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery  Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds  Consult with the wound care

1331. Emergency Nurses Association content and transcript (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/ena-slides.pdf
      September 01, 2015 - Need for resources • What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery  Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds  Consult with the wound care

1332. 6Ngc3Byq9Jeby Pwyvd6Or (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/6Ngc3byQ9jeBy_pwyvD6or
      September 01, 2014 - Other harms of inter- ventions included myocardial infarction, nerve injury, and hema- toma. … At follow-up in 2002 or 2003, mean blood pressure was 148/79 mm Hg in both groups (41). § 2.9% (44 of … nerve injuries with complete functional recovery. … The Mayo Asymptomatic Carotid Endarterectomy study reported a 1.1% rate of minor cranial nerve injury … important harms, such as nonfatal MI, per- manent cranial nerve damage, pulmonary embolism, pneu- monia, wound

1333. Final Progress Report: Shared Decision Making in Surgery To Improve Patient Safety and Reduce Liability (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/domino-report.pdf
      January 01, 2024 - Physicians already felt pressure to reduce or limit time with patients to meet scheduling demands and … outpatient treatment, unplanned admission or readmission, or emergency room visit), or new physical injury … In contrast, the nature of most errors was equipment injuries (23%), diagnostic delays or failures ( … Medical errors leading to complaints included medication errors (n=5), equipment injuries (n=3), diagnosis … and dollar amounts Patient complaints were more likely than errors to result in some new physical injury

1334. Labor and Delivery Unit Safety: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/ldu-safety-slides.html
      July 01, 2023 - Intrauterine pressure catheter or fetal scalp electrode placement. Manual rotation. … Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management.

1335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49400/psn-pdf
      May 01, 2003 - A full code ensued and after a brief time, the patient was stabilized with a blood pressure of 95/55 … or more risk factors identified only one patient with a DVT.(9) A retrospective study of pediatric trauma … Assistant Professor of Pediatrics (Anaesthesia), Harvard Medical School Chair, Pediatric Acute Lung Injury … Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases.

1336. Safety Climate on Hospital Units: A New Measure (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Blegen.pdf
      January 01, 2004 - Studies have identified a number of factors that affect the rate of worker injury. … authority.13 There is research examining the climate of safety in health care as it impacts worker injuries … reactions of supervisors, the training in use of technology, performance appraisals that include safety, pressures … perceptions of work group members regarding the protection of patients from medication errors and injuries … teamwork, risk perception, process auditing, A Hospital Safety Climate Measure 441 production pressures

1337. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet
      psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
      March 01, 2004 - preoperative period but suffered a pulseless electrical activity arrest in the operating room at the time of wound … 1997 data from the National Inpatient Sample Excludes patients with any code for cancer, trauma … Excludes patients with any diagnosis code for drug dependence, abuse of drugs, or self-inflicted injury … Decubitus ulcer Pressure sores in patients hospitalized for 4 days or longer Discharges … diagnosis among all surgical discharges Excludes patients who have principal diagnosis codes for trauma

1338. CER 226: Evidence summary_Labor Dystocia (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/Evidence%20Summary_2.pdf
      May 01, 2020 - amniotomy, supportive care measures, epidural analgesia, frequency of cervical examination, intrauterine pressure … since cesarean delivery itself increases the risk of maternal hemorrhage, venous thromboembolism, and injury … Table W summarizes the SOE for intrauterine pressure catheters versus external monitoring. … Intrauterine pressure catheters versus external monitoring: Evidence summary in women of unspecified … Low (one study) Neonatal Outcomes – Neonatal Death, major birth injury, respiratory distress transient

1339. Central Line Clot | PSNet
      psnet.ahrq.gov/web-mm/central-line-clot
      August 04, 2021 - A full code ensued and after a brief time, the patient was stabilized with a blood pressure of 95/55, … or more risk factors identified only one patient with a DVT.( 9 ) A retrospective study of pediatric trauma … Assistant Professor of Pediatrics (Anaesthesia), Harvard Medical School Chair, Pediatric Acute Lung Injury … Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases.

1340. Bundled Payment: Effects on Health Care Spending and Quality (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/bundled-payments-quality-effects_executive.pdf
      August 01, 2012 - Several studies reported outcomes separately for patients with relatively severe disease or injury and … patients with less severe disease or injury, but the results were inconsistent between studies. … limited due to differences in beneficiary characteristics, provider bargaining power, and competitive pressures … bundled payment is more effective in more highly integrated delivery settings, the role of financial pressure … Medicare prospective payment system on acute rehabilitation outcomes of patients with spinal cord injury