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psnet.ahrq.gov/issue/medication-safety-dashboard
April 15, 2020 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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psnet.ahrq.gov/issue/sign-safety
April 15, 2020 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
May 01, 2014 - Positive culture
If yes, positive for:_______________________________
CURRENT VITAL SIGNS
Blood pressure … New or increasing pus draining from wound
Y N ? New breakdown
Y N ? … New or expanding redness around wound
Y N ? Pain / tenderness
Y N ? Warmth
Y N ? … Suspected minor injury Yes No ?
Suspected serious injury Yes No ?
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - His initial systolic blood
pressure after transfer was 60 mmHg. … One of the most
insidious iatrogenic insults affecting older patients with serious injuries is the inability … Deviation in
the face of production pressure is a recipe for disaster. … Injury. 2018;49(1):130?134. doi:10.1016/j.injury.2017.09.002
7. … Injury. 2020;S0020-1383(20)30424-
1. doi:10.1016/j.injury.2020.05.017
10.
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www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
February 01, 2017 - Systolic blood pressure <90 mmHg (4).
Oxygen saturation <80% (3). … Systolic blood pressure >200 mmHg (1).
No extubations. … (i.e., 6 per 1,000 PT treatment):
80% of events were transient physiological (heart rate, blood pressure … Subjects: 2,176 trauma and burn ICU patients,
Pre (n=1044) and post (n=1132) EM program. … Slide 23: 5-Year Sustainability of Time to PT Postacute Lung Injury Diagnosis 8
Post-QI → earlier
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psnet.ahrq.gov/issue/mindful-path-nursing-accuracy-quasi-experimental-study-minimizing-medication-administration
March 03, 2019 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … August 26, 2020
Organisational strategies to implement hospital pressure ulcer prevention
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psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
November 01, 2017 - The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates … August 10, 2022
Complexity bias in the prevention of iatrogenic injury: why specific … May 13, 2020
Assessment of nursing home reporting of major injury falls for quality measurement
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic pressures, 52–54 some … Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model. … Quantification of leakage pressures after durotomy repairs in the canine. … January 23, 2019
Classifying errors in preventable and potentially preventable trauma
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-fullreport.pdf
December 17, 2019 - , seizure associated with trauma, loss of consciousness associated
with trauma, repeated vomiting, documented … These risks include dental trauma;
airway edema (swelling of the windpipe); vocal cord spasm or injury … Was there documentation of increased intracranial pressure? … The sensitivity of claims for identification of indicators of
increased intracranial pressure was 8.1 … in a
non-trauma center.
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digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2011
January 01, 2011 - Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011
Project Name
Evaluation … of AHRQ's On-time Pressure Ulcer Program
Principal Investigator
Hurd, Donna
Organization … Project Period
June 2009 - January 2012
AHRQ Funding Amount
$1,699,797
Summary: Pressure … Although substantial research has documented that preventing pressure ulcers and falls is possible, these … Information on pressure ulcer incidence provided by the facilities for a 12-month period and adjusted
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hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf
December 01, 2008 - In
contrast, 56.5 percent of adult
patients with a principal
diagnosis of pressures ulcers
were 65 … Paralysis and spinal cord
injury were common co-
existing conditions among
younger adults hospitalized … In-hospital death occurred in 11.6 percent
of stays with pressures ulcers noted as a secondary diagnosis … Patients 65 and older accounted for 56.5 percent of adult patients with a principal diagnosis of pressures … Paralysis and spinal cord injury were prominent among younger
patients, while fluid and electrolyte
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psnet.ahrq.gov/issue/systemwide-strategy-embed-equity-patient-safety-event-analysis
November 16, 2022 - Summary
February 26, 2025
Identifying resilience: a system safety review of trauma … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-nursing-staff
October 26, 2016 - September 8, 2021
A randomized trial of a multifactorial strategy to prevent serious fall injuries … Are evidence-based practices associated with effective prevention of hospital-acquired pressure … September 28, 2016
Do nurse and patient injuries share common antecedents?
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - did not recover spontaneous circulation for more than 30 minutes and sustained severe anoxic brain injury … For example, the trauma surgery service did not routinely perform a clamping trial before chest tube … the most common complication), recurrent pneumothorax, infection (including empyema), organ or vessel injury … Complications following thoracic trauma managed with tube thoracostomy. Injury. 2012;43:46-50. … Complications of tube thoracostomy for acute trauma. Am J Surg. 1980;140:738-741.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications.pptx
April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention, due to spinal injury. … when no or little urine is seen in bladder
Consider urology consultation for prostatitis and urethral trauma … Closed pressure ulcers: stage I, deep tissue injury No No, unless has chronic ISC needs Yes, if the patient … require an indwelling urinary catheter if the wound can be kept clean by other methods
Use alternatives … J Wound Ostomy Continence Nurs. 2020;47(6):601-18. PMID: 33201147.
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hcup-us.ahrq.gov/reports/statbriefs/sb237-Patient-Safety-Adverse-Events-2011-2014.pdf
January 01, 2014 - The PSIs focus on adverse events during the
hospital stay (such as pressure ulcers), complications associated … Ulcer Rate Wounds caused by unrelieved pressure on the skin usually
around bony prominences
PSI … to the body’s tissues and organs following an elective
surgery
PSI 14 Postoperative Wound
Dehiscence … requiring dialysis (70.8 percent), postoperative wound dehiscence (70.3 percent), pressure ulcers … The 10 risk-adjusted rates contributing to PSI 90 are as follows:
Pressure Ulcer Rate (PSI 03)
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … to the ED.1
12
12
Background (4)
The presence of pulmonary edema with hypoxemia and acute kidney injury … with an especially elevated diastolic pressure. … nitroglycerin (given that nitroprusside is relatively contraindicated in the setting of acute kidney injury … treating hypertensive emergencies, choosing appropriate antihypertensives for patients with end-organ injury
-
hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_2_4.jsp
January 01, 2005 - 192
Umbilical cord complication
216.7
8.676
2.0
0.014890
7,100
175
193
Trauma … complications following abortion)
2.7
0.175
2.6
0.110958
12,800
831
235
Open wounds … examination/evaluation
16.7
4.161
*
*
*
*
98
Essential hypertension (high blood pressure … 246
Fever of unknown origin
86.4
4.815
3.4
0.073659
13,300
507
244
Other injuries … during pregnancy)
220.3
8.652
3.5
0.043953
12,000
324
236
Open wounds of extremities
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psnet.ahrq.gov/issue/report-ispe-drug-shortages-survey
January 26, 2022 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
February 15, 2023 - October 10, 2018
Early identification and evaluation of severe pressure injuries.