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101. ROI for a fall prevention intervention: invest a little, save a lot. | PSNet
     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.

102. Spotlight
     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.

103. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47788/psn-pdf
     March 06, 2019 - Medical device-related pressure ulcers: a systematic review and meta-analysis. … Medical device-related pressure ulcers: A systematic review and meta-analysis. … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis … Hospital-acquired pressure ulcers are considered never events and represent a significant source of … This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related

104. Chest Tube Complications | PSNet
     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.

105. Psn-Pdf (pdf file)
     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.

106. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. | PSNet
     psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
     August 04, 2021 - From research to practice: factors affecting implementation of prospective targeted injury-detection … From research to practice: factors affecting implementation of prospective targeted injury-detection … five hospitals faced in implementing new systems for prospective detection of adverse drug events and pressure … From research to practice: factors affecting implementation of prospective targeted injury-detection

107. Core Elements of Hospital Diagnostic Excellence (DxEx). | PSNet
     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.

108. Too Many Cooks Spotlight Pdf (pdf file)
     psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
     January 01, 2020 - in one hour (versus six hours in this case) • Prolonged operative time is a surrogate for tissue injury … 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. … Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam Dressings. … Injury. 2020;S0020-1383(20)30424-1. doi:10.1016/j.injury.2020.05.017 10.

109. Spotlight
     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

110. Secured But Not Always Safe | PSNet
     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

111. Psn-Pdf (pdf file)
     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

112. A Tale of Two Falls | PSNet
     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.

113. Psn-Pdf (pdf file)
     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

114. Psn-Pdf (pdf file)
     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

115. Continuing Education | PSNet
     psnet.ahrq.gov/continuing-education
     February 26, 2025 - in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. … 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 … 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

116. Psn-Pdf (pdf file)
     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.

117. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
     January 01, 2024 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic pressures,52–54 some remain … Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model. … Quantification of leakage pressures after durotomy repairs in the canine. … Occult spinal pseudomeningocele following a trivial injury successfully treated with a lumboperitoneal

118. Psn-Pdf (pdf file)
     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

119. Blind Spot | PSNet
     psnet.ahrq.gov/web-mm/blind-spot
     July 30, 2020 - The surgery was uncomplicated—her blood pressures intraoperatively were within 20% of her baseline, and … other signs of periorbital trauma. … Eye injuries after nonocular surgery. A study of 60,965 anesthetics from 1988 to 1992. … Injuries to the visual system and other sense organs. In: Benumof J, Saidman L, eds. … COVID-19: Team and Human Factors to Improve Safety July 30, 2020 Injury

120. An integrative review exploring the perceptions of patients and healthcare professionals towards patient involvement in promoting hand hygiene compliance in the hospital setting. | PSNet
     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.