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Showing results for "pressure injury".
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121. Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. | PSNet
     psnet.ahrq.gov/issue/toward-zero-harm-mackenzie-healths-journey-toward-becoming-high-reliability-organization-and
     September 14, 2022 - reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure … injuries and healthcare-acquired infections.

122. Occurrence of no-harm incidents and adverse events in hospitalized patients with ischemic stroke or TIA: a cohort study using trigger tool methodology. | PSNet
     psnet.ahrq.gov/issue/occurrence-no-harm-incidents-and-adverse-events-hospitalized-patients-ischemic-stroke-or-tia
     August 05, 2020 - The most common preventable events were medication events , pressure injuries, and healthcare-associated

123. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet
     psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
     January 29, 2021 - The patient did not suffer permanent neurological injury from the prolonged hypoxemia, but she did require … Health care providers are frequently under time pressure to bring the next patient to the operating room … Production pressure, medical errors, and the pre-anesthesia checkout. … Production pressures among anaesthesiologists in Singapore. … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

124. Optimizing medication safety in the home. | PSNet
     psnet.ahrq.gov/issue/optimizing-medication-safety-home
     August 24, 2015 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

125. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet
     psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
     March 18, 2020 - Anesthetic factors such as difficult intubation , light anesthesia, prolonged surgery duration, or positive pressure … contents in the mouth or airway, other signs of aspiration include persistent hypoxia, high airway pressures … Positive pressure mask ventilation for an aspirating patient is not ideal due to the risk of pushing … July 31, 2024 WebM&M Cases Uterine Artery Injury … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

126. Unexplained Apnea Under Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
     December 01, 2005 - disabling adverse events, 45% of those events were caused by errors.( 6 ) In a large insurer’s study, injuries … Poor system design also makes errors difficult to intercept before injury occurs. … muscle weakness, and visual disturbances Extreme or unexpected increase or decrease in blood pressure … carrying the drug Attempt to aspirate or drain the IV tubing to point of injection If there is blood pressure … samples for ABG and serum electrolyte levels Conduct a neurological examination to exclude focal CNS injury

127. 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.

128. Examining the meaning of the language used to communicate the nursing hand-off. | PSNet
     psnet.ahrq.gov/issue/examining-meaning-language-used-communicate-nursing-hand
     July 07, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

129. What can safety cases offer for patient safety? A multisite case study. | PSNet
     psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study
     February 07, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

130. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet
     psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
     April 17, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

131. High Reliability | PSNet
     psnet.ahrq.gov/primer/high-reliability
     January 29, 2020 - reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures … A classic example is that of the military aircraft carrier: despite significant production pressures … A regional health system in Canada reported a decrease in adverse events such as falls, pressure injuries

132. If You Say So: Taking a Syringe at Face Value in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
     January 01, 2015 - Over the next few minutes, the patient's blood pressure skyrocketed to 250/135 mm Hg. … contributors to error in the current case are situational and likely include organizational culture and social pressure … toxic cultures that inhibit communication and assertion of concerns and that exert deep and pervasive pressure … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

133. Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study. | PSNet
     psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
     September 23, 2020 - March 5, 2025 A randomized trial of a multifactorial strategy to prevent serious fall injuries … May 29, 2024 WebM&M Cases Under Pressure: Delayed Diagnosis

134. An intervention to enhance nursing staff teamwork and engagement. | PSNet
     psnet.ahrq.gov/issue/intervention-enhance-nursing-staff-teamwork-and-engagement
     June 21, 2010 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

135. Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study. | PSNet
     psnet.ahrq.gov/issue/strength-safety-measures-introduced-medical-practices-prevent-recurrence-patient-safety
     May 01, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

136. What are the experiences of team members involved in root cause analysis? A qualitative study. | PSNet
     psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
     August 16, 2023 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

137. Where's the Feeding Tube? | PSNet
     psnet.ahrq.gov/web-mm/wheres-feeding-tube
     September 01, 2003 - Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury … Because of the injuries, he was unable to swallow and had to receive nutrition through a nasojejunal … Perforation March 15, 2023 WebM&M Cases Under Pressure … Post-Tracheostomy Care May 29, 2024 WebM&M Cases Under Pressure

138. Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention. | PSNet
     psnet.ahrq.gov/issue/root-causes-adverse-drug-events-hospitals-and-artificial-intelligence-capabilities-prevention
     May 20, 2020 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

139. Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project. | PSNet
     psnet.ahrq.gov/issue/improving-communication-hospital-skilled-nursing-facility-through-standardized-hand-quality
     September 08, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

140. Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. | PSNet
     psnet.ahrq.gov/issue/differences-hospitals-workplace-violence-incident-reporting-practices-mixed-methods-study
     January 19, 2022 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.