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1341. 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

1342. 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

1343. 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

1344. 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

1345. 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

1346. 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

1347. 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

1348. 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

1349. 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.

1350. 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.

1351. 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

1352. 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

1353. 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

1354. 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.

1355. JAMA JATS (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/UA7cEG8wH4xh8-fr7Lfw9q
      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 … fractures, serious injuries resulting from increased physical activity, and an increased risk for eating … Association of overweight with increased risk of coronary heart disease partly independent of blood pressure … Screening for high blood pressure in adults: U.S.

1356. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care | PSNet
      psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
      February 24, 2022 - Dental care providers are advised to: If possible, perform procedures in a negative pressure room … 6 feet apart, especially in counties with substantial or high transmission. 25 Using a negative pressure … create several challenges, including the desire to limit exposure to patients, fatigue, burnout, and pressure … care. 66 Managing necessary deviations from well-rehearsed practice, while under additional budgetary pressures … Remote diagnosis of traumatic dental injuries using digital photographs captured via a mobile phone.

1357. 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

1358. Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-143-fullreport.pdf
      April 01, 2018 - This measure calculates the rate of adverse events (patient harm)—defined as unintended physical injury … Black and Hispanic newborns are at higher risk of birth trauma (Miller, et al., 2003). … Although AEs most often result in transient harms, some lead to permanent injury and death. … : "Naloxone administration," “Health care- associated infections: positive C. difficile test,” and "Pressure … Internal pressures, such as a punitive culture that leads to underreporting of medical errors, may influence

1359. Chronic-Urinary-Retention Research (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/chronic-urinary-retention_research.pdf
      September 01, 2014 - (7 percent), and other conditions such as stroke or traumatic brain injury (29 percent). … Journal of Wound, Ostomy, & Continence Nursing. 2007 May- Jun;34(3):289-96. PMID 17505249. … disease and a history of stroke or myocardial infarction in the previous 6 months; resting blood pressure … citrate Control: placebo Definition/etiology max flow rate <15ml/min, max urethral closure pressure … Score; LUTS = lower urinary tract symptoms; MS = multiple sclerosis; MUCP = maximal urethral closure pressure

1360. High-Risk Medications, High-Risk Transfers | PSNet
      psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
      December 21, 2017 - airway displacement), hemodynamic disturbances (including cardiac arrest), nosocomial infections, and injury … More Related Resources WebM&M Cases Under Pressure