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161. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
     psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
     September 01, 2012 - Left ventricular pressures can be measured with a catheter advanced across the aortic valve. … instance, the operator was falsely reassured by the presence of a normal pressure reading, suggesting … that the tip of the catheter was not against the wall, when in fact, the pressure sensor was likely … Radiology technologists and nurses, who should be reviewing images and pressures during the case, can … Immediate recognition of iatrogenic injuries during cardiac catheterization enables more timely and effective

162. Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals | PSNet
     psnet.ahrq.gov/issue/challenges-and-potential-solutions-patient-safety-infectious-agent-isolation-environment
     October 27, 2021 - The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related … October 13, 2018 Trauma Resuscitation Using in situ Simulation Team Training (TRUST) … July 21, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

163. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46524/psn-pdf
     October 18, 2017 - Pressure Injury Prevention in Hospitals Training Program. … https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program Pressure ulcers are … designed to help hospitals implement practice and process improvements to reduce the occurrence of pressure … https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program https://psnet.ahrq.gov … /issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review https://psnet.ahrq.gov

164. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60846/psn-pdf
     January 01, 2021 - The survey found that supervisor commitment to safety was associated with lower rates of major injuries … from falls and catheter use, and that environmental safety was associated with lower rates of pressure … ulcers, major injuries from falls, and catheter use.

165. Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. | PSNet
     psnet.ahrq.gov/issue/barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-meta-synthesis
     August 25, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

166. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
     January 01, 2021 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … Injuries were divided into three groups: No Injury where the incident did not result in harm, Injury … that they represent minor injuries such as soreness, bumps, and minor abrasions. … Injuries were divided into two groups: Fall considered unassisted and Fall known to be assisted. … the most advanced stage of the pressure ulcer or suspected Deep Tissue Injury being reported?”

167. The effect of bedrails on falls and injury: a systematic review of clinical studies. | PSNet
     psnet.ahrq.gov/issue/effect-bedrails-falls-and-injury-systematic-review-clinical-studies
     March 15, 2016 - The effect of bedrails on falls and injury: a systematic review of clinical studies. … that outdated design and incorrect assembly, rather than bedrails themselves, contributed to such injuries … The effect of bedrails on falls and injury: a systematic review of clinical studies. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

168. Appendix B8: Unsafe Behavior Worksheet (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
     December 01, 2017 - ( ) Postural hypotension ≥20 mm Hg drop in systolic pressure with position change … Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions __ Low blood pressure … __ Behavior management strategies __ Increase assistance and surveillance    __ Position or pressure … _ Increase activities involvement    __ Other ___________________________ __ Reduce risk of injury

169. Appendix B31: Engineer Wheelchair Inspection | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb31.html
     December 01, 2017 - Use a tire gauge to check tire pressure if the tire is air-filled. If it is low, look for leaks. … of dirt and grime, remove and clean. ___ If air-filled tire is soft, inflate until firm and at the pressure … Brake Check The tires must be filled to the correct pressure before checking brakes.

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49615/psn-pdf
     December 01, 2010 - injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure … Int Wound J. 2008;5:315-328. [go to PubMed] 3. Lyder CH. Pressure ulcer prevention and management. … Adv Wound Care. 1999;12:22-30. [go to PubMed] 5. … Guidelines for the prevention of pressure ulcers. Wound Repair Regen. 2008;16:151-168.  … Slough or eschar may be present on some parts of the wound bed.

171. Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey. | PSNet
     psnet.ahrq.gov/issue/organisational-strategies-implement-hospital-pressure-ulcer-prevention-programmes-findings
     June 02, 2021 - Study Organisational strategies to implement hospital pressure ulcer prevention programmes … Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a … Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment … injury incidence. … injury.

172. The Forgotten Turn | PSNet
     psnet.ahrq.gov/web-mm/forgotten-turn
     August 01, 2018 - injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, … Int Wound J. 2008;5:315-328.  [go to PubMed] 3. Lyder CH. … Adv Wound Care. 1999;12:22-30.  [go to PubMed] 5. … Guidelines for the prevention of pressure ulcers. Wound Repair Regen. 2008;16:151-168.  … Slough or eschar may be present on some parts of the wound bed.

173. Don’t Bite Your Tongue. | PSNet
     psnet.ahrq.gov/web-mm/dont-bite-your-tongue
     September 18, 2024 - Changes in motor evoked potentials can indicate an impending neurologic injury and should trigger an … Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years.  … Airway injury during anesthesia: a closed claims analysis.  … Cost analysis of intubation-related tracheal injury using a national database.  … August 1, 2010 WebM&M Cases Under Pressure: Delayed

174. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
     December 01, 2017 - measures that include falls, residents who fall, residents with two or more falls and fall related serious injuries … Changes in staff organization Reduction of survey tags and lawsuits related to falls and injuries … Include alarms attached to a wheelchair and consider all types of pressure or position change alarms … Item 14 asks if the resident's blood pressure was taken after the fall. … across from the injury site and specify the type of injury.

175. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. | PSNet
     psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
     November 25, 2020 - His left calf was noted to be very tense; the surgeon confirmed elevated compartment pressures and performed … Pain out of proportion to injury severity is a hallmark sign of CS and should have been investigated … from fractures or crush injuries. … Unless there is an associated arterial injury, compartment pressure is rarely elevated sufficiently to … Interobserver variability in the measurement of lower leg compartment pressures.

176. Low Tidal Volume (Lung Protective) Ventilation Literature Review | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-lit-review.html
     January 01, 2017 - trial with 20 patients without lung disease, requiring mechanical ventilation admitted to either a trauma … regression analysis adjusted for baseline characteristics and underlying ARDS risk factors (sepsis, trauma … concentrations of TNF-alpha and of slCAM-1; Reductions of V t , with subsequently decreased peak airway pressures … The plateau airway pressures of group PV were lower than those groups of CV+PEEP (p=0.02) and CV+ZEEP … , such as multiple transfusions, trauma, sepsis, or high-risk surgery.

177. Final Progress Report: Analysis of Factors Associated With Clinical Checklist Compliance (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/sarcevic-report.pdf
     January 01, 2024 - , and (4) patients with external injuries. … 1(0-3) 0(1-3) Injury 0(0-2) 0(0-1) External 0.014 0.053 <.001* <.001* 0.92 0.13 No injury 1(0-1.5) … with penetrating injuries and those with a blunt injury. … Of 187 patients, 111 (59.4%) had external injuries. … without external injuries (p<.001, Table 1).

178. Appendix B7: Wheelchair Seating Assessment (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manwsa.html
     December 01, 2017 - Skin Breakdown __  Jell or air cushion to assist in healing skin ulcer __  Cushion to distribute pressure … ) thoracic region at most extreme point of scoliotic curve; 2) just under axilla, avoiding axillary pressure

179. Appendix A. RACI Chart | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apa.html
     October 01, 2017 - Pressure Injury Prevention Program Implementation Guide Appendix A. … RACI Chart Previous Page Next Page Table of Contents Pressure Injury Prevention Program … Implementation Guide Overview Get Ready Pressure Injury Prevention Program Phases Appendix A

180. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
     November 01, 2017 - Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .