AHRQ Search | Home Page

Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. | PSNet

psnet.ahrq.gov/issue/identifying-safety-practices-perceived-low-value-exploratory-survey-healthcare-staff-united

February 03, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals. | PSNet

psnet.ahrq.gov/issue/visitor-behaviors-can-influence-risk-patient-harm-analysis-patient-safety-reports-92

September 01, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point

September 24, 2024 - Carole Stockmeier: Patients come to us with faith, hope, and trust that we will restore health and heal wounds … safety culture and found a 37% increase in reporting, and decreases in preventable harm: 39% decrease in injuries … with falls, 37% fewer pressure injuries and a 34% reduction in central line-associated blood stream … For instance, a hospital may focus on eliminating severe pressure injuries as a preventable harm, but

The Unfamiliar Catheter | PSNet

psnet.ahrq.gov/web-mm/unfamiliar-catheter

November 01, 2006 - demonstrates that misuse of an unfamiliar medical device can lead to potentially devastating patient injury … and secondary emotional trauma for the involved health care professional. … In one hospital, direct observation of 50 nurses flushing a CVC with a positive pressure adapter revealed … Take-Home Points Unfamiliarity with a CVC can lead to a serious patient injury and have a profound … Medical device related deaths and injuries should be reported to the FDA .

Inadequate hand-off communication. | PSNet

psnet.ahrq.gov/issue/inadequate-hand-communication

April 02, 2015 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

Good Catch in the Operating Room | PSNet

psnet.ahrq.gov/web-mm/good-catch-operating-room

August 27, 2017 - About halfway through the procedure, the anesthesiologist noticed that the patient's blood pressure was … anesthesiologist administered a bolus of intravenous fluids, but over the next few minutes the patient's blood pressure … The patient required transfusion of multiple units of blood, and fortunately the injury was repaired … first challenge occurred when the anesthesiologist alerted the surgeon during the initial drop in blood pressure … Paige, MD Professor of Clinical Surgery Director of Wound Care LSU Health New Orleans Health Sciences

Delayed Evaluation of Abdominal Pain in an Elderly Patient. | PSNet

psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient

February 26, 2020 - The patient remained alert and cooperative until 2350H when her blood pressure fell to 90/58. … Nevertheless, every patient deserves to be provided with the best opportunity to survive an illness or injury … that permits all necessary interventions to be provided commensurate with the degree of illness or injury … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery Division of Trauma … 2022 WebM&M Cases Errors in Managing an Open Wound

Unseen Perils of Urinary Catheters | PSNet

psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters

January 31, 2024 - With regulatory and financial pressures directed toward reducing hospital-acquired infections, attention … They include dislodgement due to trauma, urethral erosion (traumatic hypospadias due to pressure necrosis … occurs more frequently in men who perform intermittent catheterizations frequently (e.g., spinal cord injury … J Wound Ostomy Continence Nurs. 2007;24:655-661. [go to PubMed] 2. … Assist in healing of open sacral/perineal wound in incontinent patients.

Physical Diagnosis: A Lost Art? | PSNet

psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art

January 17, 2018 - Case & Commentary: Part 1 A 57-year-old male with T8 paraplegia from a remote gunshot wound, hypertension … as follows: General: Mild respiratory distress with audible wheezing Vitals: Blood pressure … In one study, 90% of patients expected their blood pressure to be measured and their heart, lungs, abdomen … One of us (G.R.T.) has seen a patient with spinal cord injury who was transferred from an outside hospital … Clinical assessment of central venous pressure in the critically ill.

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. | PSNet

psnet.ahrq.gov/issue/one-size-fits-all-mixed-methods-evaluation-impact-100-single-room-accommodation-staff-and

July 01, 2016 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … May 11, 2019 A randomized trial of a multifactorial strategy to prevent serious fall injuries

Acute Respiratory Arrest in Pregnancy | PSNet

psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy

August 15, 2018 - Two days prior to admission, the patient presented to the obstetrics clinic with blood pressures (BPs … marked increase in her plasma volume with resultant increase in her preload (increased left atrial pressure … orders for type and frequency of blood tests, fetal monitoring, and surveillance of symptoms and blood pressure … Criteria for E stablishing Severe Preeclampsia.* • Persistent blood pressure above 160/110 mm … Related Resources WebM&M Cases Uterine Artery Injury

E-cigarette Explosion in a Patient Room | PSNet

psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room

March 15, 2023 - oxygen requirement at home was 2 liters via nasal cannula, and she used a continuous positive airway pressure … Benowitz, MD This case, of a woman who sustained burn injuries from using an electronic cigarette ( … Numerous reports have emerged of fires and explosions caused by e-cigarettes, some resulting in severe injuries … In summary, this case describes a serious injury due to use of an e-cigarette, a known ignition source … Electronic cigarette explosion and burn injuries, US emergency departments 2015–2017.

Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet

psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines

February 05, 2020 - Nitrous oxide only flows into the oxygen pipeline when the pressure in the nitrous line is higher than … When pressure in the oxygen line drops below that in the nitrous line, it is possible for an outlet to … The pressure in the oxygen and nitrous oxide pipelines as well as in the cylinders mounted on the anesthesia … When the pressure in the oxygen pipeline drops, a gas outlet may begin to deliver a hypoxic gas mixture … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

Dangerous Dialysis | PSNet

psnet.ahrq.gov/web-mm/dangerous-dialysis

June 12, 2024 - Risk factors for falls included patient age, number of comorbidities, having a lower systolic blood pressure … addition, after dialysis sessions, hemodynamic shifts can lead to transient hypotension (low blood pressure … The quality indicators include identification of medical injuries and medical errors. … Falls and fall-related injuries in older dialysis patients.

Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet

psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow

September 27, 2023 - with factitious disorder consciously and manipulatively (usually surreptitiously) produce illness or injury … advocated by most experienced practitioners. 20 Applying cricoid pressure compresses the esophagus … this communication error because the foreign body likely traversed the gastrointestinal tract without injury … Scand J Trauma Resusc Emerg Med . 2021;29(1):64. [ Free full text ] Zdravkovic M, Rice MJ, Brull SJ. … The clinical use of cricoid pressure: first, do no harm.

Measuring Patient Safety | PSNet

psnet.ahrq.gov/perspective/measuring-patient-safety

December 14, 2022 - Falls and pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing … major injury increase by 17% and pressure ulcers increase by over 40%. … healthcare-acquired infections, complications, medication safety, safety of the EMR, patient falls with injury … , and pressure injuries. … Did you take someone's blood pressure?

In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety | PSNet

psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety

December 14, 2022 - Falls and pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing … major injury increase by 17% and pressure ulcers increase by over 40%. … healthcare-acquired infections, complications, medication safety, safety of the EMR, patient falls with injury … , and pressure injuries. … Did you take someone's blood pressure?

Cognitive Overload in the ICU | PSNet

psnet.ahrq.gov/web-mm/cognitive-overload-icu

June 01, 2005 - The patient ultimately regained a pulse but required two vasopressors to maintain her blood pressure … Bedside cannulation of the central circulation for measurement of central venous pressure and for vasopressor … The patient immediately responded, with improved oxygenation and blood pressure. … radiograph provided reassurance that the central line was in the correct position without evidence of lung injury … Relative value of central-venous-pressure monitoring and blood-volume measurement in the management of

Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet

psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery

November 25, 2020 - Vital signs showed systolic blood pressure around 90 mm Hg, mean arterial pressure (MAP) 60-70, pulse … At that time, the patient’s vital signs showed a blood pressure of 88/40, mean arterial pressure of 57 … include increased blood volume, increased cardiac output, decreased vascular resistance (with lower blood pressure … For example, single parameter alerts such as a diastolic blood pressure >90 mm Hg were common in the … October 30, 2024 WebM&M Cases Uterine Artery Injury during

Getting the Diagnosis Both Right and Wrong | PSNet

psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong

May 29, 2024 - Laboratory tests showed acute kidney injury with markedly elevated levels of potassium, phosphate, and … The patient's blood pressure improved with fluids. … Six hours after admission, the patient's blood pressure started to drop, requiring further intravenous … Despite aggressive measures to maintain her circulation, blood pressures further dropped, and a code

Search AHRQ

Results