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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Ironically for this case, the greatest risk of bleeding from ALIF is usually from injury to
a major … the wound. … Trauma-induced coagulopathy: what you need to know. J Trauma Acute
Care Surg. 2024;96(2):179-185. … Vascular injury and complication in neurosurgical spine surgery. … Hetastarch during initial resuscitation from trauma. J Trauma.
2011;70(5 Suppl):S19-S21.
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psnet.ahrq.gov/node/39545/psn-pdf
May 19, 2010 - Surgical robot examined in injuries.
May 19, 2010
Carreyrou J. … https://psnet.ahrq.gov/issue/surgical-robot-examined-injuries
This newspaper article discusses complications … explains that such
errors may have been exacerbated by inadequate clinician training and production pressures … https://psnet.ahrq.gov/issue/surgical-robot-examined-injuries
https://psnet.ahrq.gov//#productionpressure
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psnet.ahrq.gov/periodic-issue/periodic-issue-463
October 30, 2024 - Commentary
Health services under pressure: a scoping review and development of … these pressures in health care settings. … in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. … 2024
A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury … A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
April 27, 2022 - wound. … Trauma-induced coagulopathy: what you need to know. … Vascular injury and complication in neurosurgical spine surgery. … Hetastarch during initial resuscitation from trauma. … J Trauma . 2011;70(5 Suppl):S19-S21. [ Available at ] Hahn RG.
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psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save-lot
September 13, 2017 - Falls and falls with injury are significant sources of morbidity and mortality and can have substantial … This study showed that after implementing the Fall TIPS program, falls and falls with injury decreased … November 3, 2021
Trauma resuscitation errors and computer-assisted decision support. … 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/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … manage potential foreign bodies, clinicians should have a low threshold for involving an experienced trauma … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery, Division of Trauma … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.
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psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
April 26, 2023 - March 7, 2018
Pressure Injury Prevention in Hospitals Training Program. … October 18, 2017
Preventing Falls With Injury.
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psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - Commonly used agents that cause severe extravasation injuries include antineoplastic, inotropic, or osmotically … Use to Promote Wound Healing In contrast, the wound healing literature generally supports the use … Treating chronic and acute wounds with warming: review of the science and practice implications. … Local heat increases blood flow and oxygen tension in wounds. Arch Surg. 1987;122:221-225. … March 5, 2025
WebM&M Cases
Under Pressure: Tracheostomy
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psnet.ahrq.gov/issue/integrative-review-exploring-perceptions-patients-and-healthcare-professionals-towards
March 06, 2019 - Citation
Related Resources From the Same Author(s)
Medical device-related pressure … March 6, 2019
A randomized trial of a multifactorial strategy to prevent serious fall injuries … September 27, 2016
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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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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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - healing.2
17
17
General Approach to Wounds (4)
Eliciting the mechanism of injury will identify factors … the possibility of injury to deeper structures causing neurovascular injuries, fractures, or, for the … , arterial injury, open fracture, and foreign material.4,5
19
19
General Approach to Wounds (6) … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - treated with albuterol without improvement, which prompted the initiation of bilevel positive airway pressure … She sustained head trauma, blunt trauma of the cervical spine, right rib fractures, and a right femur … initial ED presentation, she was alert and oriented, and her vital signs were stable, with a blood pressure … We do not know if the patient’s fall at home resulted in head trauma, which may have predisposed her … second case or contributed to a worse injury.
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psnet.ahrq.gov/node/73604/psn-pdf
August 18, 2021 - effect-providing-staff-training-and-enhanced-support-care-homes-care-
processes-safety-climate
Hospital admissions and preventable adverse events, such as falls and pressure … After 24
months, the safety climate had improved, and both falls and pressure ulcers were reduced. … effect-providing-staff-training-and-enhanced-support-care-homes-care-processes-safety-climate
https://psnet.ahrq.gov/issue/utilizing-quality-improvement-methods-prevent-falls-and-injury-falls-enhancing-resident
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury … Wounds should be irrigated with moderate pressure (5-8 psi)
irrigant to reduce bacterial counts and … manage potential foreign bodies, clinicians should have a low threshold for involving an experienced
trauma … Consulting Editor, AHRQ’s Patient Safety Network (PSNet)
Professor
Department of Surgery, Division of Trauma … Primary closure versus delayed closure for non bite traumatic
wounds within 24 hours post injury.
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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
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - use have been reported.( 6 ) The most common complications include aspiration and unintended local trauma … with LMAs and high peak inspiratory pressures, allowing for inspired gases to insufflate the stomach … LMA use can also lead to injuries secondary to high cuff pressure and volume during prolonged procedures … These increased intra-cuff pressures can cause a significant damage to surrounding tissues. … the pyriform sinus, which is where the recurrent laryngeal nerve enters, rendering it vulnerable to injury
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psnet.ahrq.gov/node/49862/psn-pdf
May 01, 2019 - She was admitted to the stroke unit and
received aggressive treatment to control her blood pressure. … This powerful attractive force can result in injury
to a patient or health care worker from any of various … Direct trauma from the accelerating ferromagnetic object striking the patient or health care worker … To this day, injuries
continue to occur in MRI scanners around the globe from ferromagnetic objects … modality—at times with
serious, and even fatal, consequences.(6-10)
The only way to avoid such events and injuries
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - treated with albuterol without
improvement, which prompted the initiation of bilevel positive airway pressure … She sustained head trauma,
blunt trauma of the cervical spine, right rib fractures, and a right femur … initial ED presentation, she was alert and oriented, and her vital signs were
stable, with a blood pressure … We do not know if the patient’s fall at home resulted in head trauma,
which may have predisposed her … case or contributed to a worse injury.
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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
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psnet.ahrq.gov/node/44845/psn-pdf
July 01, 2016 - room hospital accommodation associated with
differences in healthcare-associated infection, falls,
pressure … room hospital accommodation associated with differences in
healthcare-associated infection, falls, pressure … Falls,
pressure ulcers, and Clostridium difficile infections increased in the older patients' ward after … one-size-fits-all-mixed-methods-evaluation-impact-100-single-room-accommodation-staff-and
https://psnet.ahrq.gov/issue/preventing-falls-injury