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1361. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49668/psn-pdf
      October 01, 2012 - On physical examination, abnormal findings included dilated pupils, elevated heart rate and blood pressure … Injury Prevention and Control Policy Impact: Prescription Painkiller Overdoses.

1362. Refining Key Questions: Interactive Case Study Quiz
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/rfviia.pptx
      May 01, 2010 - guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure … brain injury (TBI) as the overall cause of mortality. … The coagulopathy develops when there is tissue injury in combination with hypotension. … Transfusions result in pulmonary morbidity and death after a moderate degree of injury. … Effect of recombinant factor VIIa as an adjunctive therapy in damage control for wartime vascular injuries

1363. Refining Key Questions: Interactive Case Study Quiz
      effectivehealthcare.ahrq.gov/sites/default/files/rfviia.pptx
      May 01, 2010 - guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure … brain injury (TBI) as the overall cause of mortality. … The coagulopathy develops when there is tissue injury in combination with hypotension. … Transfusions result in pulmonary morbidity and death after a moderate degree of injury. … Effect of recombinant factor VIIa as an adjunctive therapy in damage control for wartime vascular injuries

1364. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
      January 01, 2020 - opioid-induced respiratory depression; of those, 77% resulted in severe brain damage or death – Most injuries … should be monitored closely 25 Monitoring Component Assessment Type Vital Signs Heart Rate Blood Pressure

1365. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49779/psn-pdf
      January 01, 2017 - these failures are more likely when staff are working under high levels of stress, workload, or time pressure … Injuries are caused by a lack of differentiation between the use of infusion devices in hospitals and

1366. ElderTree Baseline Survey (pdf file)
      digital.ahrq.gov/sites/default/files/docs/survey/eldertree-baseline-survey.pdf
      October 16, 2014 - Medical support services*       ∗ reminders to take medications, taking blood pressure, monitor … weight for gain or loss, observe for injuries (bruises, limping) monitor for pain OTHER SUPPORT

1367. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
      March 01, 2016 - Staffing, Work Pressure, and Pace ................................ 4 Composite 4. … Effective Crisis Management Living a Culture of Patient Safety Policy and Brochure Medically Induced Trauma … Staffing, Work Pressure, and Pace 1. … portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury … Staffing, Work Pressure, and Pace Composite 4. Teamwork Composite 5. Staff Training Composite 6.

1368. Isolated Clot, Real Error | PSNet
      psnet.ahrq.gov/web-mm/isolated-clot-real-error
      December 01, 2013 - is sometimes observed in clinical practice, filters should not be used as a way to prevent VTE after trauma … July 1, 2011 Injuries before and after diagnosis of cancer: nationwide register … More Related Resources WebM&M Cases Under Pressure

1369. Strategies to Better Engineer Safety into Healthcare Delivery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
      March 06, 2025 - that make it more difficult for people to make errors in care delivery or experience a work-related injury … designed to reduce the transmission of healthcare-associated infections and the risk of occupational injury … Healthcare Settings includes strategies to identify risks and hazards and prevent/control work-related injury … Healthcare-Associated Infections Program (contains multiple resources and toolkits)  • Preventing Pressure

1370. First Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/tfannrpt2011.pdf
      January 01, 2012 - Adolescents High-risk alcohol use by adolescents is an important cause of preventable death and significant injury … high blood pressure in adults ages 18 years and older. … B Type 2 Diabetes Mellitus: Screening in Adults With Sustained Blood Pressure of 135/80+ The USPSTF … I Prevention of Motor Vehicle Occupant Injuries: Counseling in a Primary Care Setting for Driving Under … I Prevention of Motor Vehicle Occupant Injuries: Counseling in a Primary Care Setting for Proper Use

1371. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - how a safety pin could be aspirated, or a non-deformable endotracheal tube connector might cause a pressure … injury to the nares if left in place for more than a brief period.

1372. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
      January 01, 2023 - diuresis, diarrhea, and fluid restriction, they ordered blood products and albumin to increase oncotic pressure … responsive to fluid resuscitation,” with the added requirement for vasopressors to maintain a mean arterial pressure … perforations.21 • Other identified risk factors include older age, presence of comorbidities,22 acute kidney injury

1373. Timely Fluid Bolus for Children With Severe Sepsis or Septic Shock (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0231-fullreport.pdf
      May 01, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for treating underlying injury once shock is present. … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the

1374. Timely Antibiotics for Children With Severe Sepsis or Septic Shock (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0230-fullreport.pdf
      April 02, 2018 - Unlike adults, the diagnosis of septic shock in children does not require the presence of low blood pressure … (hypotension), as children often maintain normal blood pressure until the advanced stages of shock … A limited window of opportunity exists for therapy of the underlying injury once shock is present. … Because children often maintain their blood pressure until they are severely ill, systemic hypotension … For severe sepsis, one abstractor indicated that there was a low systolic blood pressure despite the

1375. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857059/psn-pdf
      November 29, 2023 - complications and the time period for ascertainment.11,14,17,18 The most common complications are wound … bumper” syndrome occurs in about 1-4% of cases6,9,14 when the PEG tube’s internal bumper causes focal pressure … Liver injury during PEG tube placement: report of two cases. … Trauma transitional care coordination: a mature system at work. … J Trauma Acute Care Surg. 2018;84(5):711-717. [Available at 48.

1376. In Conversation with...Joseph Britto, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
      February 01, 2007 - And of course there is increasing pressure on the system to get it right, to not make so many mistakes … Yet the pressures in the market around pay for performance and transparency may conspire to begin stripping … Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, … Rarely, the error may cause injury or death.

1377. Interpreting the Patient Safety Literature | PSNet
      psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
      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

1378. Final Progress Report: Improved Patient Safety with Information Technology (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/overhage-report.pdf
      January 01, 2024 - The report estimated more than a million injuries and nearly 100,000 deaths attributable to medical … medication opportunities (not on an indicated med); (4) failed intermediate outcomes – e.g., high blood pressures … with CHF who are euvolemic (compensated) and on a low dose of an ACE inhibitor with systolic blood pressure … of 110, diastolic blood pressure of 80, and a heart rate of 76, adding a beta blocker is the next most

1379. Coming Undone: Failure of Closure Device | PSNet
      psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
      April 01, 2006 - The bleeding was not stopped by local pressure, and he returned to the hospital, where he was found to … July 10, 2019 Classifying errors in preventable and potentially preventable trauma deaths … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

1380. Virtual Patient Advocate to Reduce Ambulatory Adverse Drug Events (pdf file)
      digital.ahrq.gov/sites/default/files/docs/publication/r18hs017196-jack-final-report-2011.pdf
      January 01, 2011 - outcomes-assessors rated on an ordinal scale from 1-6 their confidence that medical management caused an injury … (injuries rated 5 or 6 are considered ADEs); (3) outcomes-assessors then rated each AE for ameliorability … the outcomes-assessors categorized the type of each ADE as: adverse drug event, procedure-related injury … For another patient, blood pressure was reviewed in detail, including recent lab test results and goals … (if alert rated as a potential problem or problem needing timely response) n=13: Procedure related injury