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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/nurse-well-being-concept-analysis
August 25, 2021 - March 16, 2022
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/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.
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - Multiple therapies were initiated to reduce the intracranial pressure and swelling, including intubation … The "Lund protocol," derived in patients with elevated ICP in the setting of head trauma, assumes that … Continuous recording and control of ventricular fluid pressure in neurosurgical practice. … Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am. 1995;6:761-773. … Hyperventilation in head injury: a review. Chest. 2005;127:1812-1827. [go to PubMed] 5.
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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.
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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/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/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/node/49398/psn-pdf
May 01, 2003 - Patient #1 was in the trauma bay with massive injuries and profuse bleeding. … The blood pressure cuff
(which was partly fabric and partly nylon) was saturated with so much blood … General factors influencing compliance with barrier precautions include time pressures and concerns about … Until the cost-effectiveness of disposable blood pressure cuffs has
been established, we can at least … Situations
Blood Pressure Cuffs
EKG Leads
Pulse Oximetry
Defibrillators
This project was funded
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psnet.ahrq.gov/issue/ed-handoffs-observed-practices-and-communication-errors
October 19, 2022 - intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood pressure … July 21, 2021
High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients.
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - which Brennan
and colleagues defined in the Harvard Medical Practice Study in New York State as “an injury … Thoracic Surgeons offers patient safety
indicators for adult cardiac surgery, such as deep sternal wound … injuries) and hospital acquired infections (CLABSI, CAUTI). … dehiscence, and obstetric trauma. … deaths due to health care-associated venous
thromboembolism, sepsis, or patient falls; in-hospital pressure
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Patient #1 was in the trauma bay with massive injuries and profuse bleeding. … The blood pressure cuff (which was partly fabric and partly nylon) was saturated with so much blood that … General factors influencing compliance with barrier precautions include time pressures and concerns about … Until the cost-effectiveness of disposable blood pressure cuffs has been established, we can at least … Situations Blood Pressure Cuffs EKG Leads Pulse Oximetry Defibrillators
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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.
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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
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psnet.ahrq.gov/issue/guideline-implementation-team-communication
October 15, 2014 - April 14, 2011
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - Her vital signs were notable for a temperature of 38.6° C, heart rate of 115 beats per minute, blood pressure … 2 hours despite adequate fluid resuscitation
Creatinine > 2 mg/dL
Worsening hypoxemia
Acute lung injury … with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
Acute lung injury with PaO2/FiO2 … Shock
Septic shock is defined as severe sepsis with lactate ≥ 4 mmol/L or hypotension (mean arterial pressure … [MAP] < 65 mm Hg; systolic blood pressure < 90 mm Hg) not responsive to a fluid bolus
In this case,
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psnet.ahrq.gov/issue/review-patient-safety-incidents-reported-critical-care-units-north-west-england-2009-and-2010
December 02, 2009 - Pressure ulcers were the most common voluntarily reported patient safety issue in intensive care units … November 17, 2010
What’s past is prologue: organizational learning from a serious patient injury
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psnet.ahrq.gov/issue/objective-framework-evaluating-unrecognized-bias-medical-ai-models-predicting-covid-19
July 22, 2020 - June 16, 2021
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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psnet.ahrq.gov/issue/adverse-patient-safety-events-during-covid-epidemic
May 03, 2023 - June 9, 2021
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.