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psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery
December 24, 2008 - January 31, 2018
Pressure Injury Prevention in Hospitals Training Program.
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psnet.ahrq.gov/issue/drill-down-root-cause-analysis
June 15, 2016 - Related Resources From the Same Author(s)
A case of transfusion error in a trauma … May 25, 2022
Root cause analysis for hospital-acquired pressure injury.
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psnet.ahrq.gov/issue/exposure-incivility-does-not-hinder-speaking-randomised-controlled-high-fidelity-simulation
August 24, 2022 - March 30, 2022
Communication failures contributing to patient injury in anaesthesia malpractice … Related Resources
Barriers and facilitators to reporting medical device-related pressure … Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - efflux of solutions from a vessel into the surrounding tissue during an infusion” and may cause grave injury … Outcomes and management of peripheral intravenous infiltration injuries. Hand (NY) . … Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. … June 2, 2015
Implementation of the World Health Organization Trauma Care Checklist Program … WebM&M Cases
Intraosseous Line Extravasation in a Pediatric Trauma
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psnet.ahrq.gov/issue/preeminent-hospitals-penalized-over-rates-patients-injuries
January 17, 2018 - Newspaper/Magazine Article
Preeminent hospitals penalized over rates of patients’ injuries … Citation Text:
Preeminent hospitals penalized over rates of patients’ injuries. Rau J. … Citation
Citation Text:
Preeminent hospitals penalized over rates of patients’ injuries … February 16, 2022
More than 750 hospitals face Medicare crackdown on patient injuries
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psnet.ahrq.gov/node/846169/psn-pdf
March 15, 2023 - young patients because their strong
chest wall muscles can create much higher negative intrathoracic pressures … Succinylcholine is
contraindicated in patients with stroke, spinal cord injury, burns, or myotonic dystrophy … inadequate resources such as the broken drug refrigerator otherwise could have led to irreversible injury … Risk of respiratory complications and wound infection in
patients undergoing ambulatory surgery: smokers … Negative-pressure pulmonary edema. Chest.
2016;150(4):927-933. [Available at]
14.
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psnet.ahrq.gov/node/840141/psn-pdf
November 16, 2022 - reporting and improvements in safety culture, as well as decreases in adverse events such
as falls, pressure … injuries and healthcare-acquired infections.
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - High risk of errors, preventable death : Multidisciplinary trauma teams face tremendous time pressures … , and specialty situations (neurotrauma, burns, spinal cord injury, and orthopedic trauma). … For example, prompts might remind staff working with a patient with abnormally low blood pressure to … The program had a particularly large impact on the use of pressure dressings to control hemorrhage (p … Missed injuries in a level I trauma center. J Trauma. 2002 Apr;52(4):715-9.
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psnet.ahrq.gov/issue/getting-rid-never-events-hospitals
April 25, 2016 - Never events are devastating and preventable, and health care organizations are under increasing pressure … September 21, 2005
"Near injury" alters procedures at Virginia Mason.
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - High risk of errors, preventable death: Multidisciplinary trauma teams face tremendous time
pressures … , and specialty situations
(neurotrauma, burns, spinal cord injury, and orthopedic trauma). … For example, prompts might remind staff
working with a patient with abnormally low blood pressure to … The program had a particularly
large impact on the use of pressure dressings to control hemorrhage ( … Missed injuries in a level I trauma center. J Trauma. 2002
Apr;52(4):715-9.
2.
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psnet.ahrq.gov/periodic-issue/periodic-issue-294
June 30, 2021 - Study
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury … injuries. … injuries between March and July 2020. … The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed … complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury
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psnet.ahrq.gov/issue/safety-climate-associated-adverse-events-nursing-homes-national-va-study
September 08, 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.
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psnet.ahrq.gov/issue/rates-adverse-events-hospitalized-patients-after-summer-time-resident-changeover-united
June 22, 2022 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … March 23, 2012
Injury and death associated with incidents reported to the Patient Safety … Hospitals
Medicine
Medication Errors/Preventable Adverse Drug Events
Nosocomial Infections
Pressure
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - national guidelines, including those from the American College of Gastroenterology ( 7 ), the Welsh Wound … the past year; sensitivity or allergies to any of the materials used in the device; rectal or anal injury … An FMS device should not be used for a mobile patient as movement may lead to pressure on the tubing, … An FMS is unsuitable for spinal cord injury patients due to the high risk of autonomic dysreflexia that … Wounds UK. 2005;1:3:110-114. [Available at]
7.
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - The required
insufflation leads to an increase in peak inspiratory pressures, and this increase is more … pronounced during
dilation as the balloon pressure increases tracheal stress. … Patient death or serious injury associated
with intravascular air embolism that occurs while being cared … vessel may be exposed due to underlying disease (e.g., ulcers,
mucosal inflammation), scope-induced injury … Technical steps like using appropriate monitoring, minimizing insufflation and dilation pressures to
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psnet.ahrq.gov/issue/supporting-perioperative-safety-during-disaster-through-clinical-crisis-education
July 05, 2017 - August 12, 2020
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … January 15, 2025
Identifying resilience: a system safety review of trauma and orthopaedic
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psnet.ahrq.gov/issue/obstetric-quality-and-safety
February 25, 2009 - November 15, 2017
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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psnet.ahrq.gov/issue/contributing-factors-pediatric-ambulatory-diagnostic-process-errors-project-redde
November 30, 2022 - Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and … included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure … August 9, 2011
Delayed or missed diagnosis of cervical spine injuries.
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psnet.ahrq.gov/issue/care-home-safety-incidents-and-safeguarding-reports-relating-hospital-care-home-transitions
July 17, 2024 - Common incidents included pressure injuries, medication errors , and premature discharge. … Long-Term Care
Geriatrics
Discontinuities, Gaps, and Hand-Off Problems
Medical Complications
Pressure
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psnet.ahrq.gov/issue/hsj-patient-safety-virtual-congress
April 17, 2024 - September 29, 2021
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.