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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … new-recommendations-duty-hours-acgme-task-force
decreased risk of motor vehicle crash involvement and needlestick injury … Simplify the treatment when tired or under time pressure
When clinicians are tired or pressured for … Work schedule, needle use, and needlestick injuries among
registered nurses. … Can workplace rest breaks prevent work-related injuries related to long
working hours?
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psnet.ahrq.gov/issue/exploring-nursing-sensitive-events-home-healthcare-national-multicenter-cohort-study-using
August 05, 2020 - The most common types of nursing-sensitive events were falls , pressure injuries, healthcare-associated … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - care hospitals, including the ability to care for patients requiring
mechanical ventilation, complex wound … Inpatient rehabilitation facilities (IRFs) care for patients recovering from surgery, trauma, or an … evaluation by a physician but do require
services such as intensive nursing, physical therapy, or wound … injuries) during their
stay, half of which were preventable. … injuries, and falls).
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psnet.ahrq.gov/issue/improve-health-care-focus-fixing-systems-not-people
September 08, 2021 - October 26, 2022
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … ; this change was associated with decreased risk of motor vehicle crash involvement and needlestick injury … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours? … Effects of coffee on ambulatory blood pressure in older men and women: a randomized controlled trial.
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psnet.ahrq.gov/issue/abc-handover-impact-shift-handover-emergency-department
June 17, 2010 - June 17, 2010
Teams under pressure in the emergency department: an interview study. … Settings Help Improve Management of Sepsis
May 31, 2023
High delayed and missed injury … rate after inter-hospital transfer of severely injured trauma patients.
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psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
May 26, 2016 - Considered a never event for hospitalized patients, falls that result in serious injury remain relatively … October 5, 2015
Preventing in-facility pressure ulcers as a patient safety strategy: … March 13, 2013
Venous thromboembolism after trauma: a never event?
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight … Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy … staggering racial and ethnic disparities in maternal morbidity and mortality.
3
UTERINE ARTERY INJURY … survived, she suffered another cardiac arrest with
residual cognitive impairment.
8
UTERINE ARTERY INJURY … rate
>24 or <10/minuteRespiratory rate
Systolic >155 or <80 mm Hg
Diastolic >105 or <45 mm Hg
Blood pressure
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psnet.ahrq.gov/issue/inevitability-physician-burnout-implications-interventions
April 17, 2024 - September 18, 2024
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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psnet.ahrq.gov/issue/pros-and-cons-electronic-prescribing-children
October 30, 2024 - November 2, 2016
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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psnet.ahrq.gov/issue/implementing-standardized-safe-surgery-program-reduces-serious-reportable-events
October 30, 2024 - November 2, 2016
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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psnet.ahrq.gov/periodic-issue/periodic-issue-413
October 31, 2023 - Specialization, setting-specific emphasis of improvement actions and task-oriented production pressures … Newspaper/Magazine Article
Early identification and evaluation of severe pressure … injuries. … Pressure injuries are a significant and preventable patient safety threat. … summarizes recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure
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psnet.ahrq.gov/periodic-issue/periodic-issue-392
April 26, 2023 - Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … injuries. … Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions … injuries. … Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions
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psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
May 01, 2014 - May 22, 2019
Fake it 'til you make it: pressures to measure up in surgical training. … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - Multiple services were
contacted to assist with management of this complicated wound. … After conservative treatment for nearly
three weeks, the wound did not show any appreciable healing, … To prevent iatrogenic injuries of this type,
physicians, nurses, and pharmacists must work together … When the infusion exceeds this maximum rate, it may cause lowering of blood
pressure.1
Calcium chloride … Management of severe calcium chloride extravasation injury: a case
report.
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psnet.ahrq.gov/issue/mindful-path-nursing-accuracy-quasi-experimental-study-minimizing-medication-administration
March 03, 2019 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … August 26, 2020
Organisational strategies to implement hospital pressure ulcer prevention
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psnet.ahrq.gov/periodic-issue/periodic-issue-422
January 04, 2024 - The authors attributed low positive predictive value (PPV) in three of the PSIs (pressure injury, falls … The authors attributed low positive predictive value (PPV) in three of the PSIs (pressure injury, falls … they consider child abuse in the differential diagnosis and approaches to identifying non-accidental trauma … Neither a sensory examination nor wound exploration was documented. … diagnostic imaging as well as strategies to improve diagnosis and mitigate human error when treating hand injuries
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psnet.ahrq.gov/issue/nurse-burnout-predicts-self-reported-medication-administration-errors-acute-care-hospitals
August 25, 2021 - August 25, 2021
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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psnet.ahrq.gov/issue/sleep-and-circadian-misalignment-hospitalist-review
July 15, 2020 - May 14, 2018
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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psnet.ahrq.gov/issue/nursing-assessment-continuous-vital-sign-surveillance-improve-patient-safety-medicalsurgical
May 01, 2019 - April 12, 2023
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.