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Showing results for "pressure injury".
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121. Fall-related injuries in acute care: reducing the risk of harm. | PSNet
     psnet.ahrq.gov/issue/fall-related-injuries-acute-care-reducing-risk-harm
     March 28, 2018 - Review Fall-related injuries in acute care: reducing the risk of harm. … Fall-related injuries in acute care: reducing the risk of harm. … Fall-related injuries in acute care: reducing the risk of harm. … injuries and medication administration errors: an integrative review. … August 21, 2019 Root cause analysis for hospital-acquired pressure injury.

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41985/psn-pdf
     October 26, 2016 - The most common adverse events reported were pressure ulcers and fall- related injuries or deaths. … serious-reportable-events-healthcare-2011-update https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities … https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities

123. 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.

124. Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice. | PSNet
     psnet.ahrq.gov/issue/barriers-and-facilitators-reporting-medical-device-related-pressure-ulcers-qualitative
     April 07, 2019 - Study Barriers and facilitators to reporting medical device-related pressure ulcers … Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration … Hospital-acquired pressure ulcers, categorized as a never event, are underreported , particularly when … Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting … injuries.

125. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-456
     September 25, 2024 - injuries, catheter-related infections, and six-out-of-seven surgery-related safety indicators. … injuries, catheter-related infections, and six-out-of-seven surgery-related safety indicators. … Scand J Trauma Resusc Emerg Med . 2024; 32 (1) :78 . … 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

126. 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

127. Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. | PSNet
     psnet.ahrq.gov/issue/estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-medical-and-surgical
     July 11, 2018 - Some adverse events are sensitive to aspects of nursing care , including pressure injuries , falls, … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure

128. 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

129. Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. | PSNet
     psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
     November 01, 2017 - The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates … August 10, 2022 Complexity bias in the prevention of iatrogenic injury: why specific … May 13, 2020 Assessment of nursing home reporting of major injury falls for quality measurement

130. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866343/psn-pdf
     December 31, 2024 - 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

131. Don’t Bite Your Tongue. | PSNet
     psnet.ahrq.gov/web-mm/dont-bite-your-tongue
     September 18, 2024 - Changes in motor evoked potentials can indicate an impending neurologic injury and should trigger an … Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years.  … Airway injury during anesthesia: a closed claims analysis.  … Cost analysis of intubation-related tracheal injury using a national database.  … August 1, 2010 WebM&M Cases Under Pressure: Delayed

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60856/psn-pdf
     August 26, 2020 - His initial systolic blood pressure after transfer was 60 mmHg.  … One of the most insidious iatrogenic insults affecting older patients with serious injuries is the inability … 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. … Injury. 2020;S0020-1383(20)30424- 1. doi:10.1016/j.injury.2020.05.017  10.

133. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860380/psn-pdf
     January 10, 2024 - The authors attributed low positive predictive value (PPV) in three of the PSIs (pressure injury, falls

134. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
     psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
     March 09, 2022 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic pressures, 52–54 some … Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model. … Quantification of leakage pressures after durotomy repairs in the canine. … January 23, 2019 Classifying errors in preventable and potentially preventable trauma

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60846/psn-pdf
     January 01, 2021 - The survey found that supervisor commitment to safety was associated with lower rates of major injuries … from falls and catheter use, and that environmental safety was associated with lower rates of pressure … ulcers, major injuries from falls, and catheter use.

136. The Magnetic Deflection | PSNet
     psnet.ahrq.gov/web-mm/magnetic-deflection
     November 18, 2016 - 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 … These include, among others: Direct trauma from the accelerating ferromagnetic object striking the patient … To this day, injuries continue to occur in MRI scanners around the globe from ferromagnetic objects being … modality—at times with serious, and even fatal, consequences.( 6-10 ) The only way to avoid such events and injuries

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851099/psn-pdf
     June 28, 2023 - and procalcitonin levels were elevated, serum creatinine was 1.5 mg/dL (consistent with acute kidney injury … when the patient is hypotensive.7,8,9 Arterial injection of drugs can cause ischemia by direct vessel injury … https://psnet.ahrq.gov//#29 https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient … Display arterial and central venous pressures on the monitor Displaying the pressure measured at the … Injection injury of an aberrant superficial radial artery requiring surgical intervention.  

138. 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

139. Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. | PSNet
     psnet.ahrq.gov/issue/taking-heat-or-taking-temperature-qualitative-study-large-scale-exercise-seeking-measure
     November 02, 2016 - measurement program in the United Kingdom, the NHS Safety Thermometer, which measured incidence of pressure … June 28, 2017 Towards international consensus on patient harm: perspectives on pressure … injury policy. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … See More About The Topic Hospitals Physicians Medicine Nosocomial Infections Pressure

140. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45251/psn-pdf
     August 24, 2016 - Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery … center, this news article describes how factors such as production pressure and insufficient assessment … advancing-patient-safety-cataract-surgery-betsy-lehman-center-expert-panel-report https://psnet.ahrq.gov/web-mm/production-pressures