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321. 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.

322. 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.

323. 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.

324. Psn-Pdf (pdf file)
     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

325. Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes | PSNet
     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.

326. Sources of nurse-sensitive inpatient safety improvement. | PSNet
     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

327. Psn-Pdf (pdf file)
     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.

328. Psn-Pdf (pdf file)
     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.

329. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls | PSNet
     psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
     December 18, 2024 - no injury. … injury to that person and their psyche. … I was a site Principal Investigator (PI) for the Strategies to Reduce Injuries and Develop Confidence … In hospitals, falls with injuries can lead to other adverse outcomes including pressure injuries or … One study found that providing patients at risk for falls with Smart Socks , which contain pressure

330. 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).

331. 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.

332. 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.

333. Reducing potential errors associated with insulin administration: an integrative review. | PSNet
     psnet.ahrq.gov/issue/reducing-potential-errors-associated-insulin-administration-integrative-review
     March 31, 2021 - March 31, 2021 Intervention study for the reduction of medication errors in elderly trauma … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

334. Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. | PSNet
     psnet.ahrq.gov/issue/medication-errors-hospitals-literature-review-disruptions-nursing-practice-during-medication
     August 26, 2015 - August 26, 2015 Towards international consensus on patient harm: perspectives on pressure … injury policy.

335. PCA safety data review after clinical decision support and smart pump technology implementation. | PSNet
     psnet.ahrq.gov/issue/pca-safety-data-review-after-clinical-decision-support-and-smart-pump-technology
     October 08, 2016 - From the Same Author(s) Towards international consensus on patient harm: perspectives on pressure … injury policy.

336. Correlates of missed or late versus timely diagnosis of dementia in healthcare settings. | PSNet
     psnet.ahrq.gov/issue/correlates-missed-or-late-versus-timely-diagnosis-dementia-healthcare-settings
     March 09, 2022 - July 1, 2017 Towards international consensus on patient harm: perspectives on pressure … injury policy.

337. Long-term Care and Patient Safety | PSNet
     psnet.ahrq.gov/primer/long-term-care-and-patient-safety
     February 24, 2022 - 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 … daily 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).

338. Another fatal failure at King/Drew. | PSNet
     psnet.ahrq.gov/issue/another-fatal-failure-kingdrew
     May 03, 2017 - November 18, 2011 Popular blood thinner causing deaths, injuries in nursing homes. … June 11, 2014 Interactive effects of nurse-experienced time pressure and burnout on patient

339. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33822/psn-pdf
     January 01, 2017 - The day I arrived at Alcoa, even though they were already in the top 20% or so of avoiding injuries to … their workforce, I announced we should be an injury-free workplace. … And over the 13 years I was there we got close to achieving zero injuries. … safety, namely to identify as quickly as possible anything gone wrong—including medication errors, pressure … probably no better than average at all the other things they do, like central line infections and pressure

340. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33722/psn-pdf
     December 01, 2011 - reversible or can be improved with this patient that will not only reduce their fall risk and harm injury … In this area it seems that the pressure for early mobilization seems like a very good idea, but probably … But they should not receive an injury as a result of a fall. … The same as with pressure ulcers. … We have nearly eliminated pressure ulcers here at Ascension, and it was all built around a strategy