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psnet.ahrq.gov/issue/longitudinal-study-multifaceted-intervention-reduce-newborn-falls-while-preserving-rooming
March 20, 2019 - implementation, the hospital achieved one year without any newborn falls and there were no fall-related injuries … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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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/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/issue/staffing-matters-every-shift
January 20, 2021 - December 12, 2012
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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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.
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - emergencies, eclampsia (convulsions), hypertensive crisis (a severe increase in the mother's blood pressure … decreased to a nadir of 21.8 percent (primary rate below ten percent), there had been no brachial plexus injuries … retrospective observational study found that the program led to a 70 percent reduction in brachial plexus injuries … following shoulder dystocia and the virtual elimination of permanent injuries. 6 An additional retrospective … Seton Family of Hospitals: Where the Birth Trauma Rate is Essentially Zero.
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psnet.ahrq.gov/issue/nurse-interrupted-development-realistic-medication-administration-simulation-undergraduate
September 27, 2016 - September 27, 2016
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what-does-literature-tell-us
February 11, 2013 - March 4, 2020
Root cause analysis for hospital-acquired pressure injury.
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psnet.ahrq.gov/issue/learning-design-development-and-implementation-medication-safety-thermometer
November 02, 2016 - October 30, 2024
Towards international consensus on patient harm: perspectives on pressure … injury policy.
-
psnet.ahrq.gov/issue/interventions-improve-hand-hygiene-compliance-icu-systematic-review
January 23, 2019 - June 28, 2017
Towards international consensus on patient harm: perspectives on pressure … injury policy.
-
psnet.ahrq.gov/issue/incidence-and-cost-adverse-events-victorian-hospitals-2003-04
July 13, 2010 - June 7, 2018
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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psnet.ahrq.gov/issue/measurement-adverse-events-using-incidence-flagged-diagnosis-codes
June 18, 2013 - December 16, 2009
Towards international consensus on patient harm: perspectives on pressure … injury policy.
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psnet.ahrq.gov/issue/top-five-review-post-pandemic-patient-safety-priorities
July 10, 2024 - demands during the crisis to affect falls, medication safety, healthcare associated infections , and pressure … injuries.
-
psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - 4 mmol/L or hypotension (mean arterial pressure [MAP] 4) In this case, the patient presented to
the … mental status
Lactate > 2 mmol/L
Urinary output
Creatinine > 2 mg/dL
Worsening hypoxemia
Acute lung injury … with PaO2/FiO2
Acute lung injury with PaO2/FiO2
Bilirubin > 2 mg/dL
Platelet count 9/L
International … normalized ratio > 1.5
Partial thromboplastin time > 60 seconds
MAP: mean arterial pressure
SBP: … systolic blood pressure
Reprinted from (4) with permission from Wolters Kluwer Health, Inc.
-
psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - emergencies, eclampsia (convulsions), hypertensive crisis (a severe increase in the
mother's blood pressure … decreased to a nadir of 21.8
percent (primary rate below ten percent), there had been no brachial plexus injuries … retrospective observational study found that the program led to a 70 percent
reduction in brachial plexus injuries … following shoulder dystocia and the virtual elimination of
permanent injuries.6 An additional retrospective … Seton Family of Hospitals: Where the Birth Trauma Rate is
Essentially Zero.
-
psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-nursing-staff
October 26, 2016 - September 8, 2021
A randomized trial of a multifactorial strategy to prevent serious fall injuries … Are evidence-based practices associated with effective prevention of hospital-acquired pressure … September 28, 2016
Do nurse and patient injuries share common antecedents?
-
psnet.ahrq.gov/node/846127/psn-pdf
March 15, 2023 - later, he was seen by the urologist and was found to
be tachycardic and febrile, with acute kidney injury … Rectal perforation is an uncommon process,
most often related to traumatic injury or associated with … The affected tissue demonstrates markedly compromised integrity and impaired wound
healing, which dramatically … increases the risk for complications including leak, inadvertent injury, and
failure of surgical repair … Limitations
In the past decade, surgical patients have grown increasingly complex,3 and there is growing pressure
-
psnet.ahrq.gov/issue/sources-nurse-sensitive-inpatient-safety-improvement
July 07, 2021 - Increased spending on both improved outcomes in catheter-related blood stream infections, pressure ulcers … September 24, 2016
Assessment of nursing home reporting of major injury falls for quality
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psnet.ahrq.gov/issue/nursing-management-medication-errors
November 02, 2022 - September 19, 2018
System approach to prevent common bile duct injury and enhance performance … January 12, 2011
Interactive effects of nurse-experienced time pressure and burnout on