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1. Pressure Injury Prevention in Hospitals Training Program. | PSNet
   psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
   May 01, 2017 - Multi-use Website Pressure Injury Prevention in Hospitals Training Program. … Citation Text: Pressure Injury Prevention in Hospitals Training Program. … Pressure ulcers are a common hospital-acquired condition that can lead to patient harm . … Injury Prevention in Hospitals Training Program. … September 6, 2013 Preventing in-facility pressure ulcers as a patient safety strategy

2. Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence. | PSNet
   psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence
   August 25, 2021 - Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence. … injuries . … The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed … Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence. … June 1, 2022 Root cause analysis for hospital-acquired pressure injury.

3. Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. | PSNet
   psnet.ahrq.gov/issue/root-cause-analysis-identify-contributing-factors-development-hospital-acquired-pressure
   July 20, 2022 - injuries. … Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. … injuries. … June 15, 2016 Root cause analysis for hospital-acquired pressure injury. … September 30, 2020 Root cause analysis for hospital-acquired pressure injury.

4. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. | PSNet
   psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
   March 03, 2021 - cases, have a 15% mortality rate, and account for 81% of trocar injury-related deaths. 3,4 Bowel injuries … wound closure. … Unintended retention of drain material in contaminated wounds is a known problem, but studies documenting … J Trauma . 2007;62(4):1051-1052. [ Available at ] Anagnostakos K, Thiery A, Sahan I. … Retained negative pressure wound therapy foams as a cause of infection persistence.

5. Intraosseous Line Extravasation in a Pediatric Trauma Patient | PSNet
   psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
   September 29, 2021 - Her wounds led to significant blood loss. … arterial blood pressure. 23 Elevated compartment pressure leads initially to venous congestion, then … transferred to the OR for surgical exploration, debridement, and possible closure of her traumatic wounds … Injury . 2017;48:S22–S25. [ Available at ] Shuler MS, Reisman WM, Kinsey TL, et al. … Injury . 1994;25(6):379–81. [ Free full text ] Günal I, Köse N, Gürer D.

6. Nothing Called Small Surgery | PSNet
   psnet.ahrq.gov/web-mm/nothing-called-small-surgery
   February 01, 2023 - injury to the skin and soft tissues, and ischemic injury resulting in digital necrosis. … Arguably the most severe complication of digital tourniquets, ischemic injuries, have two principal causes … Excessive tourniquet pressures cause ischemic injury by vascular compression, which can lead to intimal … First, the use of a self-made tourniquet likely applied excessive pressure, which caused vascular injury … J Orthop Trauma. 2010 Jun;24(6):387–8.   Smith IM, Austin OMB, Knight SL.

7. Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. | PSNet
   psnet.ahrq.gov/issue/shift-shift-nursing-handover-interventions-associated-improved-inpatient-outcomes-falls
   July 07, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … injuries and medication administration errors: an integrative review. … injuries, medication administration errors). … injuries and medication administration errors: an integrative review.

8. A Laceration that Needed a Proper Exam, Not an X-Ray | PSNet
   psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
   November 25, 2020 - In a study of 165 patients undergoing wound exploration after hand laceration, 32% of tendon injuries … Explore wounds for evidence of arterial bleeding, foreign body, tendon injury, and arthrotomy. … A blood pressure cuff applied proximal to the wound is another option. … If a tendon injury cannot be ruled out after wound exploration and functional testing, assume an occult … Medico-legal risks associated to hand and wrist trauma.

9. Surgeon commitment to trauma care decreases missed injuries. | PSNet
   psnet.ahrq.gov/issue/surgeon-commitment-trauma-care-decreases-missed-injuries
   June 15, 2012 - Study Surgeon commitment to trauma care decreases missed injuries. … Surgeon commitment to trauma care decreases missed injuries. … Surgeon commitment to trauma care decreases missed injuries. … March 9, 2009 Interactive effects of nurse-experienced time pressure and burnout on patient … June 25, 2009 Missed injuries in trauma patients: a literature review.

10. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
    psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
    March 15, 2023 - The patient subsequently underwent surgical repair of the tracheal injury. … obstruction (e.g., obstructive sleep apnea; stridor and air hunger due to vocal cord paralysis or neck trauma … intubate, ventilatory support for neuromuscular disease, and as an adjunct to head/neck surgery or trauma … preventable through careful procedural and post-placement care. 6 Patient-related risk factors that affect wound … injuries can occur due to local tissue damage caused by tissue ischemia at high cuff pressures. 15

11. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery | PSNet
    psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
    January 29, 2021 - However, it is associated with several positioning injuries. … In rare circumstances, significant hypoperfusion with ischemic injury to the calf muscles may result … Pressures above 30 mm Hg are worrisome, but the diagnosis can be easily missed if the pressure is measured … Early evaluation and fasciotomy by an orthopedic or trauma surgeon are key to preventing permanent injury … Int Wound J . 2008;5(2):315-328. [ Free full text ] Matsen FA 3rd.

12. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
    psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
    January 12, 2022 - Injuries The risk of pressure injuries of the skin and soft tissue has increased during the pandemic … Injury Advisory Panel, and recommendations developed by researchers on the prevention of pressure injuries … Medical device-related pressure injuries during the COVID-19 pandemic. … The other thing that we saw related to pressure injuries was a type of skin lesion the National Pressure … COVID skin looks very much like deep tissue injury, or other types of pressure injury, but is actually

13. COVID-19 Pandemic Impact on Healthcare Associated Conditions | PSNet
    psnet.ahrq.gov/curated-library/covid-19-pandemic-impact-healthcare-associated-conditions
    April 17, 2025 - Study Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … injuries. … injuries between March and July 2020. … The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed

14. CE/MOC Quizzes | PSNet
    psnet.ahrq.gov/cme
    February 26, 2025 - On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. … in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. … A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without … The commentary highlights the importance of evaluating patient risk of wound infection and poor wound … healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up

15. PSNet Curated Library (pdf file)
    psnet.ahrq.gov/print/pdf/node/74279
    January 01, 2022 - Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence. … of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure … injuries. … visitation-restrictions-patient-experience-and-safety-outcomes-critical https://psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence

16. Interactive effects of nurse-experienced time pressure and burnout on patient safety: a cross-sectional survey. | PSNet
    psnet.ahrq.gov/issue/interactive-effects-nurse-experienced-time-pressure-and-burnout-patient-safety-cross
    September 23, 2009 - Study Interactive effects of nurse-experienced time pressure and burnout on patient … Interactive effects of nurse-experienced time pressure and burnout on patient safety: a cross-sectional … The combination of burnout and time pressures appeared to be associated with patient safety risks, … May 9, 2012 Surgeon commitment to trauma care decreases missed injuries. … May 22, 2013 System approach to prevent common bile duct injury and enhance performance

17. 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.

18. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. | PSNet
    psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
    January 06, 2018 - Review Preventing in-facility pressure ulcers as a patient safety strategy: a systematic … Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. … Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. … December 8, 2021 Pressure Injury Prevention in Hospitals Training Program. … injury policy.

19. Never Events | PSNet
    psnet.ahrq.gov/primer/never-events
    June 15, 2024 - , while being cared for in a healthcare setting Care management events Patient death or serious injury … associated with a  fall  while being cared for in a healthcare setting Any stage 3, stage 4, and unstageable pressure … Because Never Events are devastating and preventable, health care organizations are under increasing pressure … Surgery December 15, 2024 Identifying resilience: a system safety review of trauma … See More About The Topic Sentinel Event Never Events Hospitals Operating Room Pressure

20. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
    psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
    November 27, 2019 - The Case A 65-year-old man presented to a Level III trauma center with bilateral lower extremity paralysis … The patient was then transferred to a Level I trauma center that could provide a higher level of care … that results in wide fluctuation of blood pressure. … The combination of a supraphysiologic blood pressure target and the patient’s altered blood pressure … ’s spinal cord injury.