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Showing results for "pressure injury".
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321. Patient Safety Indicators | PSNet
     psnet.ahrq.gov/primer/patient-safety-indicators
     June 15, 2024 - 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

322. A systemwide strategy to embed equity into patient safety event analysis. | PSNet
     psnet.ahrq.gov/issue/systemwide-strategy-embed-equity-patient-safety-event-analysis
     November 16, 2022 - Summary February 26, 2025 Identifying resilience: a system safety review of trauma … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

323. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. | PSNet
     psnet.ahrq.gov/issue/adverse-events-rehabilitation-hospitals-national-incidence-among-medicare-beneficiaries
     January 09, 2019 - provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury … Nearly half of the events were considered preventable, with the most common types of events including pressure

324. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet
     psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
     April 01, 2008 - confirming that the tip of the catheter was in the lower half of the superior vena cava, he closed the wound … operating room, was called to see the patient who was pale, crying inconsolably, with fluctuating blood pressure … The proceduralist must also be on the lookout for injury to surrounding structures (such as arteries, … More posterior approaches increase the risk of intercostal artery injury. 12 Although the method of … Iatrogenic injury to the intercostal artery: aetiology, diagnosis and therapeutic intervention. 

325. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis | PSNet
     psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
     October 28, 2020 - antibiotics with some initial improvement in his symptoms and blood pressure. … Laboratory test results revealed a mildly elevated white count, acute kidney injury, and elevated liver … The patient's blood pressure continued to trend downward to 60/40 mm Hg. … elevated white blood cell count) and end-organ dysfunction (elevated liver function tests, acute kidney injury … Sight August 1, 2009 WebM&M Cases Missing Trauma

326. Report on the ISPE Drug Shortages Survey. | PSNet
     psnet.ahrq.gov/issue/report-ispe-drug-shortages-survey
     January 26, 2022 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

327. Eliminating vincristine administration events. | PSNet
     psnet.ahrq.gov/issue/eliminating-vincristine-administration-events
     February 15, 2023 - October 10, 2018 Early identification and evaluation of severe pressure injuries.

328. ER doctors misdiagnose patients with unusual symptoms. | PSNet
     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.

329. Indiana Medical Error Reporting System. | PSNet
     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.

330. High nursing staff turnover in nursing homes offers important quality information. | PSNet
     psnet.ahrq.gov/issue/high-nursing-staff-turnover-nursing-homes-offers-important-quality-information
     September 16, 2020 - June 7, 2023 Accuracy of pressure ulcer events in US nursing home ratings. … May 27, 2020 Assessment of nursing home reporting of major injury falls for quality measurement

331. Safety culture, safety climate, and safety performance in healthcare facilities: a systematic review. | PSNet
     psnet.ahrq.gov/issue/safety-culture-safety-climate-and-safety-performance-healthcare-facilities-systematic-review
     October 20, 2021 - (Syphilis) is Still Stumping Healthcare Providers May 26, 2021 Production pressure … June 10, 2020 A critical review: moral injury in nurses in the aftermath of a patient

332. The impacts of medication shortages on patient outcomes: a scoping review. | PSNet
     psnet.ahrq.gov/issue/impacts-medication-shortages-patient-outcomes-scoping-review
     March 10, 2021 - February 7, 2024 Impact of time pressure on dentists' diagnostic performance. … March 2, 2016 Learning from no-fault treatment injury claims to improve the safety of

333. Accuracy of infection reporting in US nursing home ratings. | PSNet
     psnet.ahrq.gov/issue/accuracy-infection-reporting-us-nursing-home-ratings
     August 24, 2022 - Download Citation Related Resources From the Same Author(s) Accuracy of pressure … February 10, 2015 Assessment of nursing home reporting of major injury falls for quality

334. Hierarchy and medical error: speaking up when witnessing an error. | PSNet
     psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
     April 14, 2011 - July 19, 2023 Towards international consensus on patient harm: perspectives on pressure … injury policy.

335. Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study. | PSNet
     psnet.ahrq.gov/issue/risk-adjusted-survival-adults-following-hospital-cardiac-arrest-day-week-and-time-day
     July 01, 2017 - November 2, 2016 Towards international consensus on patient harm: perspectives on pressure … injury policy.

336. Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis. | PSNet
     psnet.ahrq.gov/issue/incidence-never-events-among-weekend-admissions-versus-weekday-admissions-us-hospitals
     November 03, 2015 - September 28, 2023 Towards international consensus on patient harm: perspectives on pressure … injury policy.

337. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74251/psn-pdf
     January 26, 2022 - confirming that the tip of the catheter was in the lower half of the superior vena cava, he closed the wound … operating room, was called to see the patient who was pale, crying inconsolably, with fluctuating blood pressure … The proceduralist must also be on the lookout for injury to surrounding structures (such as arteries … In this patient, an injury to the intercostal artery suggests that the technique utilized to insert … Iatrogenic injury to the intercostal artery: aetiology, diagnosis and therapeutic intervention. 

338. How safety is compromised when hospital equipment is a poor fit for patients who are obese. | PSNet
     psnet.ahrq.gov/issue/how-safety-compromised-when-hospital-equipment-poor-fit-patients-who-are-obese
     October 07, 2020 - the identified events resulted in a delay in care and 41% resulted in temporary harm (e.g., falls, pressure … injuries, skin tears, abrasions).

339. How can interventions more directly address drivers of unprofessional behaviour between healthcare staff? | PSNet
     psnet.ahrq.gov/issue/how-can-interventions-more-directly-address-drivers-unprofessional-behaviour-between
     October 09, 2024 - December 19, 2018 Association of hospital participation in a regional trauma quality … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

340. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49601/psn-pdf
     April 01, 2010 - , including self-induced "digital trauma." … Similar to bleeding from other sites, it is most effectively controlled by direct pressure. … Pinching the upper lip "pressure point" also diminishes blood coming in from the upper lip artery. … Not only do these injuries create additional bleeding sources, they are commonly mistaken for the original … septum to avoid a septal perforation.(5) Moisturizing the nasal cavity is important while the cautery wound