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141. 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

142. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet
     psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
     March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause … reviews findings of the subsequent root cause analysis , which determined training weaknesses, time pressures … , and distractions within the team due to the chaotic nature of trauma care . … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

143. 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

144. An innovative mobile approach for patient safety services: the case of a Taiwan health care provider. | PSNet
     psnet.ahrq.gov/issue/innovative-mobile-approach-patient-safety-services-case-taiwan-health-care-provider
     September 27, 2017 - Citation Related Resources From the Same Author(s) Surgeon commitment to trauma … care decreases missed injuries. … June 15, 2012 System approach to prevent common bile duct injury and enhance performance … August 30, 2023 Interactive effects of nurse-experienced time pressure and burnout on

145. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49725/psn-pdf
     January 01, 2015 - Benefits include measurement of important parameters (e.g., PA occlusion wedge pressure [an indirect … indication of left atrial pressure, a surrogate for left ventricular function], cardiac output, and … hurry-up" situation should be a red flag that leads to recognition of the danger of such production pressures … While it is tempting to look at a case like this and focus only on understaffing or production pressures … Under all perioperative circumstances, but particularly with dangerously increased production pressure

146. 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.  

147. Social capital and knowledge sharing: effects on patient safety. | PSNet
     psnet.ahrq.gov/issue/social-capital-and-knowledge-sharing-effects-patient-safety
     September 15, 2011 - Related Resources From the Same Author(s) System approach to prevent common bile duct injury … September 15, 2011 Surgeon commitment to trauma care decreases missed injuries. … June 15, 2012 Interactive effects of nurse-experienced time pressure and burnout on patient … January 9, 2011 The culture of a trauma team in relation to human factors.

148. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-299
     July 28, 2021 - injuries. … Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. … injuries. … Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. … (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound

149. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet
     psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
     January 29, 2021 - His peak airway pressures were initially 23-25 cm H 2 O but suddenly increased to 48-52 about 30 minutes … Obesity is often associated with difficult ventilation because high airway pressures are required to … Thirty minutes into the operation the airway pressures suddenly increased from 25 to 50 cm of H 2 O and … Pneumothorax can occur in trauma patients who may have undiagnosed rib fractures. … Airway management in trauma.

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

151. The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet
     psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
     July 10, 2024 - September 27, 2016 Towards international consensus on patient harm: perspectives on pressure … injury policy. … August 7, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

152. Haste Makes Care Unsafe | PSNet
     psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
     January 07, 2015 - Benefits include measurement of important parameters (e.g., PA occlusion wedge pressure [an indirect … indication of left atrial pressure, a surrogate for left ventricular function], cardiac output, and mixed … hurry-up" situation should be a red flag that leads to recognition of the danger of such production pressures … While it is tempting to look at a case like this and focus only on understaffing or production pressures … Under all perioperative circumstances, but particularly with dangerously increased production pressure

153. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867429/psn-pdf
     December 18, 2024 - 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. … Occult spinal pseudomeningocele following a trivial injury successfully treated with a lumboperitoneal

154. Applying HFMEA to prevent chemotherapy errors. | PSNet
     psnet.ahrq.gov/issue/applying-hfmea-prevent-chemotherapy-errors
     September 27, 2017 - Citation Related Resources From the Same Author(s) Surgeon commitment to trauma … care decreases missed injuries. … March 9, 2009 System approach to prevent common bile duct injury and enhance performance … May 22, 2013 Interactive effects of nurse-experienced time pressure and burnout on patient

155. Differences in the reporting of care-related patient injuries to existing reporting systems. | PSNet
     psnet.ahrq.gov/issue/differences-reporting-care-related-patient-injuries-existing-reporting-systems
     December 12, 2018 - Commentary Differences in the reporting of care-related patient injuries to existing … Differences in the reporting of care-related patient injuries to existing reporting systems. … Differences in the reporting of care-related patient injuries to existing reporting systems. … Related Resources From the Same Author(s) Success in hospital-acquired pressure

156. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/862983/psn-pdf
     February 28, 2024 - His peak airway pressures were initially 23-25 cm H2O but suddenly increased to 48-52 about 30 minutes … Obesity is often associated with difficult ventilation because high airway pressures are required to … Thirty minutes into the operation the airway pressures suddenly increased from 25 to 50 cm of H2O and … Pneumothorax can occur in trauma patients who may have undiagnosed rib fractures. … Airway management in trauma. Emerg Med Clin North Am. 2018;36(1):61-84. [ Free full text] 5.

157. Patient Safety Indicators at an academic veterans affairs hospital: addressing dual goals of clinical care and validity. | PSNet
     psnet.ahrq.gov/issue/patient-safety-indicators-academic-veterans-affairs-hospital-addressing-dual-goals-clinical
     August 09, 2023 - accurate data capture interventions to improve rates of the composite PSI-90 and three individual PSIs ( pressure … Postoperative PE/DVT, postoperative sepsis, and composite PSI-90 all decreased, while pressure ulcer … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … More About The Topic Hospitals Hospital Medicine Nurse Care Nosocomial Infections Pressure

158. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49636/psn-pdf
     October 01, 2011 - year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease was admitted to a trauma … service after injuries suffered from an assault and battery. … The patient's injuries included a left shoulder dislocation and a minimally displaced fracture of a … After reviewing the medical records, the PT noted the initial shoulder injury on admission. … In addition to providing a general assessment, the PT expressed concern that the shoulder injury had

159. Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. | PSNet
     psnet.ahrq.gov/issue/barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-meta-synthesis
     August 25, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

160. Using community detection techniques to identify themes in COVID-19-related patient safety event reports. | PSNet
     psnet.ahrq.gov/issue/using-community-detection-techniques-identify-themes-covid-19-related-patient-safety-event
     July 29, 2020 - (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors , pressure … June 16, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.