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441. 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.

442. 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

443. 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.

444. 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.

445. The optimal use of telehealth to deliver safe patient care. | PSNet
     psnet.ahrq.gov/issue/optimal-use-telehealth-deliver-safe-patient-care
     October 10, 2018 - October 10, 2018 Early identification and evaluation of severe pressure injuries.

446. Becoming a High Reliability Organization. | PSNet
     psnet.ahrq.gov/issue/becoming-high-reliability-organization
     May 04, 2015 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

447. 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

448. 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

449. 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.

450. Misdiagnoses: a hidden risk of genetic testing. | PSNet
     psnet.ahrq.gov/issue/misdiagnoses-hidden-risk-genetic-testing
     July 10, 2019 - November 23, 2016 Costs of medical injuries in Utah and Colorado. … November 28, 2016 Medical misdiagnoses put pressure on patients to stay engaged.

451. Medical Expenditure Panel Survey Topics
     meps.ahrq.gov/mepsweb/data_stats/MEPS_topics.jsp
     January 27, 2023 - Priority Conditions -- High Blood Pressure … -- High Cholesterol Injuries

452. Medical Expenditure Panel Survey Topics
     meps.ahrq.gov/data_stats/MEPS_topics.jsp
     January 27, 2023 - Priority Conditions -- High Blood Pressure … -- High Cholesterol Injuries

453. 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

454. Eliminating Preventable Harms During Pediatric Intubation | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-nishisaki.html
     July 01, 2025 - Advanced Education and Innovation, Children’s Hospital of Philadelphia Chair, Pediatric Acute Lung Injury … experiencing respiratory failure, which is caused by various conditions, including pneumonia, asthma attacks, injuries … in five children who undergo the procedure face complications, including breathing issues, low blood pressure … Nishisaki also serves as Chair of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

455. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013.html
     January 01, 2018 - 2 In 2010 an HHS Office of the Inspector General (OIG) team identified the rate of harm—that is, injuries … The estimate for deaths associated with pressure ulcers was based primarily on the paper by Zhan and … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … This estimate is based on analysis of data from HCUP identifying injuries in 7.45 million hospital discharge … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure

456. Nursing surveillance: a concept analysis | PSNet
     psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
     May 26, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

457. Review: bringing patient safety to the forefront through structured computerisation during clinical handover. | PSNet
     psnet.ahrq.gov/issue/review-bringing-patient-safety-forefront-through-structured-computerisation-during-clinical
     January 13, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

458. Implementation of the Centers for Medicare & Medicaid Services' nonpayment policy for preventable hospital-acquired conditions in rural and nonrural US hospitals. | PSNet
     psnet.ahrq.gov/issue/implementation-centers-medicare-medicaid-services-nonpayment-policy-preventable-hospital
     September 16, 2020 - The study looked at four nursing-sensitive adverse outcomes: pressure ulcers, falls with injuries, catheter-associated … hospitals had significantly fewer of these hospital-acquired conditions, except for patient falls with injury

459. Legislative Report to the General Assembly: Adverse Event Reporting. | PSNet
     psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting
     May 20, 2009 - The most common adverse events reported were pressure ulcers and fall-related injuries or deaths .

460. Bloody BP Cuff | PSNet
     psnet.ahrq.gov/web-mm/bloody-bp-cuff
     June 21, 2016 - Patient #1 was in the trauma bay with massive injuries and profuse bleeding. … The blood pressure cuff (which was partly fabric and partly nylon) was saturated with so much blood that … General factors influencing compliance with barrier precautions include time pressures and concerns about … Until the cost-effectiveness of disposable blood pressure cuffs has been established, we can at least … Situations Blood Pressure Cuffs EKG Leads Pulse Oximetry Defibrillators