AHRQ Search | Home Page

Near Miss with Bedside Medications | PSNet

psnet.ahrq.gov/web-mm/near-miss-bedside-medications

February 01, 2006 - On further history, he revealed that he had recently increased his beta-blocker, a blood pressure medication … In case of injury, there may have been no attempt at recovery, or the attempts may have been unsuccessful … From the Same Author(s) Perspective Removing Insult from Injury—Disclosing … 2004 A randomized trial of a multifactorial strategy to prevent serious fall injuries

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

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

September 24, 2024 - 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

Some Patients Can't Wait: Improving Timeliness of Emergency Department Care | PSNet

psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care

November 25, 2020 - Her vital signs included: blood pressure 154/113 mmHg, heart rate 75 beats/minute, respiratory rate 16 … Despite high levels of ED crowding, there is mounting pressure to see more patients in less time and … Patients with dangerous medical conditions and traumatic injuries may present with normal or near-normal … Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review. … June 14, 2023 WebM&M Cases Under Pressure: Delayed

Saved by ECMO | PSNet

psnet.ahrq.gov/web-mm/saved-ecmo

May 05, 2017 - Epidural anesthesia is often preferred as it avoids the increase in PVR that accompanies positive pressure … inability of external compressions to generate enough force to overcome elevated pulmonary arterial pressures … Related Resources WebM&M Cases Uterine Artery Injury

Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet

psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong

March 31, 2021 - when) treated in a timely and aggressive manner. 1 Rarely, NSTIs can occur as a severe postoperative wound … If he or she described a ‘wound infection in a plastic surgery patient,’ for example, this would have … Burnout Physician burnout (also referred to as “moral injury”) is an ongoing topic of discussion in medicine … survey of subspecialty surgeons: “while EGS surgeons appear to meet [a clinical] need and relieve some pressure … Journal of Trauma and Acute Care Surgery . 2018 July;85(1):208-214.

Human Factors Engineering | PSNet

psnet.ahrq.gov/primer/human-factors-engineering

December 15, 2024 - anesthesia were integral to the redesign of anesthesia equipment, significantly reducing the risk of injury … critical system property, reflecting the organization's capacity to bounce back in the face of continuing pressures

Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet

psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery

September 25, 2019 - Due to the delayed diagnosis, the patient suffered permanent brain injury requiring around-the-clock … These barriers include professional hierarchy, time pressure, challenging workloads, and inadequate structures … Post-Tracheostomy Care May 29, 2024 WebM&M Cases Under Pressure … Infusion July 31, 2023 WebM&M Cases Under Pressure

Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet

psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality

October 01, 2004 - Mostly in response to increasing pressure from the hospital's administration to improve compliance with … Intramuscular injection site injuries masquerading as pressure ulcers. Wounds. 2003;15:302-312.

Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination | PSNet

psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination

April 29, 2020 - On arrival, she was in septic shock with systolic blood pressure in the 80’s. … Common examples include pneumonia, Clostridium difficile infection, pressure injuries, delirium, and … diarrhea in an incontinent patient with skin breakdown on the “backside” should have raised an alarm, as wound … The use of a video visit for wound care is possible as skin and wound tissue can be adequately evaluated … Wesley Valdes, DO Telehealth and Wound Specialist Sacramento, CA wesley.valdes@gmail.com Garth

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet

psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication

August 01, 2012 - complications and the time period for ascertainment. 11,14,17,18 The most common complications are wound … bumper” syndrome occurs in about 1-4% of cases 6,9,14 when the PEG tube’s internal bumper causes focal pressure … Liver 4 , 10 , 13-15 , 21-25 or spleen injury 20 are exceedingly rare complications of PEG placement … Liver injury during PEG tube placement: report of two cases. … Trauma transitional care coordination: a mature system at work.

Duplicate Therapies in Retail Pharmacy | PSNet

psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy

August 05, 2022 - confusion, the patient ran out of his medication and his daughter and home health nurse noted poor blood pressure … This lapse resulted in poor blood pressure control, but fortunately no harmful outcomes. … errors have the potential to be serious and may result in adverse drug events (ADE), which are patient injuries … What changes you will make to your blood pressure medications?”

Do Me a Favor | PSNet

psnet.ahrq.gov/web-mm/do-me-favor

September 12, 2016 - Both doctors and nurses recounted professional requests for health care "favors" include taking blood pressures … In this case, the resident may not have been fully competent to perform the exam (resulting in injury … Additionally, failing to include nursing in procedures exposes patients to risks of injury related to

Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement

September 24, 2024 - 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 … Carole Stockmeier: Patients come to us with faith, hope, and trust that we will restore health and heal wounds

Beyond the Pandemic: Creating Total Systems Safety | PSNet

psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety

August 30, 2023 - Studies show that an increase in healthcare-acquired infections, falls, and pressure ulcers has occurred … Similar increases were observed in falls and pressure ulcers at skilled nursing facilities and preventable … States, we have since experienced higher rates of preventable infections, as well as increases in pressure … measures are associated with measuring and reporting specific harms, such as an infection, falls with injury … what’s troubling our workforce and distinguish among conditions such as burnout, moral distress and injury

In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet

psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety

August 30, 2023 - States, we have since experienced higher rates of preventable infections, as well as increases in pressure … measures are associated with measuring and reporting specific harms, such as an infection, falls with injury … what’s troubling our workforce and distinguish among conditions such as burnout, moral distress and injury … Studies show that an increase in healthcare-acquired infections, falls, and pressure ulcers has occurred … Similar increases were observed in falls and pressure ulcers at skilled nursing facilities and preventable

Unintended Consequences of CPOE | PSNet

psnet.ahrq.gov/web-mm/unintended-consequences-cpoe

September 01, 2004 - She presented with sepsis and acute kidney injury with a creatinine of 2.0 mg/dL (up from a baseline … creatinine improved but remained elevated at 1.6 mg/dL and the team felt the persistent acute kidney injury … Figure , many of which are similar in appearance and might easily be selected by mistake given time pressure … have identified this and related problems prior to their being discovered in the context of patient injury

Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet

psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer

May 01, 2005 - Angina is typically described as a pressure-like or squeezing sensation in the chest, associated with … remember that electrocardiographic changes are not seen in unstable angina, as there is no permanent injury … limit Table adapted from Long et al. (2017) 9 1 Examples of risk factors include retrosternal pain, pressure

Cultural Dimensions of Depression | PSNet

psnet.ahrq.gov/web-mm/cultural-dimensions-depression

September 01, 2018 - Emigration to the United States has put pressure on these traditional values, particularly as the roles … present with somatic complaints.( 3 ) A related fact is that many Vietnamese have experienced significant trauma … Trauma contributed the largest role to mental disorders in the Vietnamese group.( 5 ) In our own Vietnamese … Trauma, PTSD, and the longer-term mental health burden amongst Vietnamese refugees: a comparison with … abnormalities and mental health sequelae in South Vietnamese ex-political detainees who survived traumatic head injury

Opioid Overdose as a Patient Safety Problem | PSNet

psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem

May 01, 2017 - required emergency care due to these products, making opioids one of the most common causes of iatrogenic injury … nonfatal overdose go on to receive prescription opioids again and remain at high risk of subsequent injury … most important steps that clinicians, individually and collectively, can take to reduce opioid-related injuries … We know that people with a history of substance use disorders, people with histories of childhood trauma … inability to balance these complex forces appropriately with the idea of pain as a fifth vital sign and the pressures

Misplaced Nasogastric Tube Resulting in Aspiration | PSNet

psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration

August 01, 2009 - She was afebrile, tachycardic (120 beats per minute), with a normal blood pressure (109/51) and excellent … ulceration or necrosis, chronic gastric irritation leading to gastrointestinal bleeding from gastritis or pressure … approximately 30 to 35 cm allows repositioning of misplaced tubes and can potentially prevent pulmonary injury

Search AHRQ

Results