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241. Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. | PSNet
     psnet.ahrq.gov/issue/determining-skills-needed-frontline-nhs-staff-deliver-quality-improvement-findings-six-case
     March 30, 2022 - Multifactorial interventions to reduce duration and variability in delays to identification of serious injury … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

242. Complications of ECMO During Transport | PSNet
     psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
     January 27, 2021 - The most common complications of ECMO are bleeding from cannulation sites (15-20%) or surgical wounds … Brain injury during venovenous extracorporeal membrane oxygenation. … Pressures – does the pump produce a pressure adequate for flow? What are the pressure trends? … Pressures are monitored before (pre-pump pressure), between pump and oxygenator (pre-oxygenator), and … January 11, 2017 Evaluation of wound photography for remote postoperative assessment

243. Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review. | PSNet
     psnet.ahrq.gov/issue/effects-computerized-decision-support-system-implementations-patient-outcomes-inpatient-care
     November 06, 2019 - effective for managing blood glucose and blood transfusions and for preventing venous thromboembolism , pressure … ulcers , acute kidney injury, and incipient clinical deterioration. … June 28, 2023 Implementation of the World Health Organization Trauma Care Checklist Program

244. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-290
     May 26, 2021 - J Trauma Acute Care Surg . 2021; 90(2) :403-412 . … Study Assessing patients 2019 experiences with medical injury reconciliation processes … Pharmacies are high-pressure environments generating conditions that undermine safety. … by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. … norepinephrine was initiated to maintain adequate spinal cord perfusion, with a target mean arterial pressure

245. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-295
     June 30, 2021 - injuries and medication administration errors: an integrative review. … injuries, medication administration errors). … injuries and medication administration errors: an integrative review. … injuries, medication administration errors). … complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury

246. Missed nursing care in emergency departments: a scoping review. | PSNet
     psnet.ahrq.gov/issue/missed-nursing-care-emergency-departments-scoping-review
     November 03, 2021 - include overcrowding and patients with complex care needs, which may result in medication errors, pressure … injuries, or patient deterioration. … More About The Topic Emergency Departments Emergency Nursing Administration Errors Pressure

247. Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital complications: a medical record review across nine Swiss hospitals. | PSNet
     psnet.ahrq.gov/issue/validity-16-ahrq-patient-safety-indicators-identify-hospital-complications-medical-record
     November 29, 2023 - The authors attributed low positive predictive value (PPV) in three of the PSIs (pressure injury, falls

248. Hospital inpatients' experiences: percentage of parents who reported how often providers prevented mistakes and helped them to report concerns. | PSNet
     psnet.ahrq.gov/issue/hospital-inpatients-experiences-percentage-parents-who-reported-how-often-providers-prevented
     February 14, 2023 - March 21, 2018 Pressure Injury Prevention in Hospitals Training Program.

249. Learning and sharing safety lessons to improve patient care. | PSNet
     psnet.ahrq.gov/issue/learning-and-sharing-safety-lessons-improve-patient-care
     August 07, 2019 - View More Related Resources Root cause analysis for hospital-acquired pressure … injury.

250. Health care management during Covid-19: insights from complexity science. | PSNet
     psnet.ahrq.gov/issue/health-care-management-during-covid-19-insights-complexity-science
     July 22, 2020 - October 26, 2022 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73389/psn-pdf
     June 16, 2021 - estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients- medical-and-surgical Some adverse events are sensitive to aspects of nursing care, including pressure … injuries, falls, hospital- acquired urinary tract infections, and medication administration errors.

252. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet
     psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
     January 29, 2021 - chest wall muscles can create much higher negative intrathoracic pressures than those of elderly patients … 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.

253. Check the Anesthesia Machine | PSNet
     psnet.ahrq.gov/web-mm/check-anesthesia-machine
     August 01, 2006 - are difficult to compare, current estimates put medication error rates at 1 in 100 anesthetics.( 2 ) Injury … from such errors are estimated to occur with 1% of errors.( 3 ) By extrapolation, then, the risk of injury … American Society of Anesthesiologists Closed Claims Project recently presented an update on patient injuries … Medication error etiology is multifactorial and includes a distracting environment and production pressure … Patient injuries from anesthesia gas delivery equipment: a closed claims update.

254. TeamSTEPPS Core Curriculum. | PSNet
     psnet.ahrq.gov/issue/teamstepps-core-curriculum
     August 01, 2012 - July 12, 2018 Pressure Injury Prevention in Hospitals Training Program.

255. Using a learning system approach to improve safety for prone-position ventilation patients. | PSNet
     psnet.ahrq.gov/issue/using-learning-system-approach-improve-safety-prone-position-ventilation-patients
     January 10, 2024 - Issues identified included medical device-related pressure injuries and device dislodgement, concerns … March 7, 2018 Information flow during pediatric trauma care transitions: things falling … 2019 Work system barriers and facilitators in inpatient care transitions of pediatric trauma … May 18, 2022 Error reduction in trauma care: lessons from an anonymized, national, multicenter

256. Medical malpractice: why is it so hard for doctors to apologize? | PSNet
     psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize
     August 24, 2011 - August 24, 2011 Assessment of nursing home reporting of major injury falls for quality … February 5, 2020 Accuracy of pressure ulcer events in US nursing home ratings.

257. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73998/psn-pdf
     October 27, 2021 - Blood products and intravenous fluids were infused under pressure into the external jugular intravenous … efflux of solutions from a vessel into the surrounding tissue during an infusion” and may cause grave injury … If an internal jugular venous catheter is placed, the venous pressure should be transduced, and the … Outcomes and management of peripheral intravenous infiltration injuries. Hand (NY). … Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma.

258. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60268/psn-pdf
     April 29, 2020 - The most common complications of ECMO are bleeding from cannulation sites (15-20%) or surgical wounds … Neurologic injury in adults supported with veno-venous extracorporeal membrane oxygenation for respiratory … Brain injury during venovenous extracorporeal membrane oxygenation. … Pressures – does the pump produce a pressure adequate for flow? What are the pressure trends? … Pressures are monitored before (pre-pump pressure), between pump and oxygenator (pre-oxygenator), and

259. The effects of harm events on 30-day readmission in surgical patients. | PSNet
     psnet.ahrq.gov/issue/effects-harm-events-30-day-readmission-surgical-patients
     July 31, 2019 - The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%) … Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … injuries.

260. Instruments and warning signs for identifying and evaluating the frequency of adverse events in intermediate and long-term care centres: a narrative systematic review. | PSNet
     psnet.ahrq.gov/issue/instruments-and-warning-signs-identifying-and-evaluating-frequency-adverse-events
     July 20, 2022 - Common adverse events impacting this population include adverse drug events, delirium , malnutrition, pressure … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.