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421. Another fatal failure at King/Drew. | PSNet
     psnet.ahrq.gov/issue/another-fatal-failure-kingdrew
     May 03, 2017 - November 18, 2011 Popular blood thinner causing deaths, injuries in nursing homes. … June 11, 2014 Interactive effects of nurse-experienced time pressure and burnout on patient

422. How real-time data can change the patient safety game. | PSNet
     psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
     July 07, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48085/psn-pdf
     June 19, 2019 - The health system sought to prevent pressure ulcers, adverse drug events, falls with injury, health … psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals https://psnet.ahrq.gov/issue/success-hospital-acquired-pressure-ulcer-prevention-tale-two-data-sets

424. Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Technical Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0206-technicalspecs.pdf
     May 01, 2016 - Exclusions • Denominator/Numerator Exclusions o Trauma-related headache or pain (Table … IMG3) on the day of or within 7 days prior to imaging o Head trauma or suspected abuse/neglect (Table … 339.43 Other complicated 339.44 OTHER Post- traumatic headache 339.2x Acute pain due to trauma … excision of foreign body from brain 61570 Craniectomy or craniotomy; with treatment of penetrating wound … 852.x Other/unspecified intracranial hemorrhage following injury 853.x Intracranial injury of other

425. People, processes, health IT and accurate patient identification. | PSNet
     psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
     April 11, 2018 - April 11, 2018 Early identification and evaluation of severe pressure injuries.

426. Keeping patients on track with preventative care during pandemic. | PSNet
     psnet.ahrq.gov/issue/keeping-patients-track-preventative-care-during-pandemic
     April 11, 2018 - October 10, 2018 Early identification and evaluation of severe pressure injuries.

427. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
     January 01, 2017 - Patients Adverse Events4 9 patients had 14 adverse events (<1% of activities) Falls to knees without injury … (5) Systolic blood pressure <90 mmHg (4) Oxygen saturation <80% (3) Nasal feeding tube removal (1) … Systolic blood pressure >200 mmHg (1) No extubations No patients required added therapy or increased … sessions (i.e., 6 per 1,000 PT treatment) 80% of events were transient physiological (heart rate, blood pressure … Safety Program for Mechanically Ventilated Patients 5-Year Sustainability of Time to PT Postacute Lung Injury

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49697/psn-pdf
     December 01, 2013 - are difficult to compare, current estimates put medication error rates at 1 in 100 anesthetics.(2) Injury … from such errors are estimated to occur with 1% of errors.(3) By extrapolation, then, the risk of injury … American Society of Anesthesiologists Closed Claims Project recently presented an update on patient injuries … Medication error etiology is multifactorial and includes a distracting environment and production pressure … Patient injuries from anesthesia gas delivery equipment: a closed claims update.

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49636/psn-pdf
     October 01, 2011 - year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease was admitted to a trauma … service after injuries suffered from an assault and battery. … The patient's injuries included a left shoulder dislocation and a minimally displaced fracture of a … After reviewing the medical records, the PT noted the initial shoulder injury on admission. … In addition to providing a general assessment, the PT expressed concern that the shoulder injury had

430. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
     January 29, 2021 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … ; this change was associated with decreased risk of motor vehicle crash involvement and needlestick injury … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours? … Effects of coffee on ambulatory blood pressure in older men and women: a randomized controlled trial.

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852807/psn-pdf
     August 30, 2023 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … new-recommendations-duty-hours-acgme-task-force decreased risk of motor vehicle crash involvement and needlestick injury … Simplify the treatment when tired or under time pressure When clinicians are tired or pressured for … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours?

432. Nursing handoffs: a systematic review of the literature. | PSNet
     psnet.ahrq.gov/issue/nursing-handoffs-systematic-review-literature
     January 08, 2025 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

433. Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
     January 01, 2021 - Patient outcome variables Patient falls and injury falls • Patient falls/1,000 patient days. … • Injury falls/1,000 patient days. … • Percent of patients with suspected deep tissue injury. 3 Table 1. … • Percent of patients with hospital-acquired suspected deep tissue injury. … ulcers stages III and IV, as well as fall and injury fall incidence and rates.

434. AHRQ Patient Safety Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/PS-tools-2024.pdf
     January 01, 2024 - Web: ahrq.gov/goinghomeguide/ Pressure Ulcers Preventing Pressure Ulcers: A Toolkit for Improving … Web: ahrq.gov/pressureulcertoolkit The Pressure Injury Prevention in Hospitals Training Program supports … the training of hospital staff on how to implement AHRQ’s Preventing Pressure Ulcers in Hospitals … injury prevention. … approaches to design that target six areas of safety: infections, falls, medication errors, security, injuries

435. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
     May 01, 2017 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management. … McRoberts maneuver used concurrently with suprapubic pressure [Call time] (hh:mm:ss) ____:____:____ … The ideal approach is for the clinician to put pressure in the antecubital fossa of the posterior arm … This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated

436. Putoolssect7 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
     February 16, 2011 - Pressure ulcers are sterile wounds. 36. … Pressure ulcers are sterile wounds. False 36. … If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … unit staff for pressure ulcer practice Certified Wound Care Nurse · Assesses wounds, does complex

437. ER doctors misdiagnose patients with unusual symptoms. | PSNet
     psnet.ahrq.gov/issue/er-doctors-misdiagnose-patients-unusual-symptoms
     August 05, 2008 - Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding … May 31, 2023 Non-accidental Injuries in Infants Attending the Emergency Department.

438. Indiana Medical Error Reporting System. | PSNet
     psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
     July 15, 2009 - problems in the 279 incidents reported in 2018 -- when the last report was published -- were advanced pressure … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

439. Copying and pasting of examinations within the electronic medical record. | PSNet
     psnet.ahrq.gov/issue/copying-and-pasting-examinations-within-electronic-medical-record
     June 12, 2013 - September 9, 2010 A randomized trial of a multifactorial strategy to prevent serious fall injuries … October 12, 2016 Towards international consensus on patient harm: perspectives on pressure … injury policy.

440. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet
     psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
     May 01, 2018 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … patients first present to the ED. 1 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