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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/medication-safety-dashboard
April 15, 2020 - 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/sign-safety
April 15, 2020 - 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/patient-safety-1
April 15, 2020 - 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/periodic-issue/periodic-issue-404
August 30, 2023 - Study
Incidence and severity of medication reconciliation discrepancies in trauma … This study sought to determine the incidence of completed medication reconciliation for admitted trauma … hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury … injuries. … injuries, or patient deterioration.
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psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - improved functional independence at 4 and 12 months.( 12-14 ) Hip fracture is a common and serious injury … , which in turn increases the risk of delirium, thromboembolism, pneumonia, pressure ulcers, and significant … Injury. 2018;49:1458-1460. [go to PubMed] 2. Cummings SR, Black DM, Rubin SM. … J Orthop Trauma. 2006;20:172-180. [go to PubMed] 12. … J Orthop Trauma. 2014;28:e49-e55.
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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/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/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/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.
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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/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/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
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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/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/node/61080/psn-pdf
October 28, 2020 - Risk factors associated with rebleeding include high systolic pressure, the presence of an
intracerebral … The clipping of cerebral aneurysms is technically difficult with a
risk of unintentional injury to branch … psnet.ahrq.gov//#18
Neuromonitoring during aneurysm clipping has been shown to reduce the risk of injury … Inflammation as a link between brain injury and heart damage: the model
of subarachnoid hemorrhage. … Intraoperative evoked potential monitoring for detecting cerebral
injury during adult aneurysm clipping
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psnet.ahrq.gov/issue/er-doctors-misdiagnose-patients-unusual-symptoms
August 05, 2008 - Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding … May 31, 2023
Non-accidental Injuries in Infants Attending the Emergency Department.
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psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
July 15, 2009 - problems in the 279 incidents reported in 2018 -- when the last report was published -- were advanced pressure … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.