-
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
-
psnet.ahrq.gov/issue/misdiagnoses-hidden-risk-genetic-testing
July 10, 2019 - November 23, 2016
Costs of medical injuries in Utah and Colorado. … November 28, 2016
Medical misdiagnoses put pressure on patients to stay engaged.
-
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.
-
psnet.ahrq.gov/issue/barriers-and-enablers-affecting-patient-engagement-managing-medications-within-specialty
December 12, 2014 - patient engagement in medication monitoring, ranging from unavailability of clinicians to production pressures … September 14, 2009
Time for a change in injury and trauma care delivery: a trauma death
-
psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
January 15, 2020 - July 31, 2019
Early identification and evaluation of severe pressure injuries.
-
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
-
psnet.ahrq.gov/node/867357/psn-pdf
December 18, 2024 - The patient arrived at the ED
with seizures, tachypneic with a respiratory rate of 30, blood pressure … significant reduction in the number of
unrecognized esophageal intubations and cases of hypoxic brain injury … P stands for pneumothorax, which typically occurs in trauma patients with rib fractures or patients … J Trauma Inj. 2019;32(3):136-142. [Free full
text]
7. Xuan Q, Lyu Z, Chen Q, et al. … Continuous positive airway pressure versus high-flow
nasal cannula oxygen therapy for acute hypoxemic
-
psnet.ahrq.gov/issue/impacts-using-community-health-volunteers-coach-medication-safety-behaviors-among-rural
September 15, 2011 - Related Resources From the Same Author(s)
System approach to prevent common bile duct injury … September 15, 2011
Interactive effects of nurse-experienced time pressure and burnout
-
psnet.ahrq.gov/issue/human-right-based-approach-dealing-adverse-events-residential-care-facilities
May 27, 2011 - June 7, 2023
Accuracy of pressure ulcer events in US nursing home ratings. … March 10, 2021
Assessment of nursing home reporting of major injury falls for quality
-
psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - 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 of
-
psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - The cause of death was documented as hip trauma from the fall at the nursing home. … , 1 such as fractures or head trauma, falls can have important psychological impacts on individuals … Likewise, her blood pressure recordings, lying, sitting or standing, were not noted so we don’t know … to risk reduction for this resident might have been to evaluate and monitor lying and standing blood pressures … Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older
-
psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - should be considered around 14 days of intubation in an adult population to avoid
laryngotracheal injury … Tracheostomy devices can
cause pressure ulcers, particularly along the inferior aspect of the tracheostomy … Steps for tracheostomy wean include: i) wean from positive pressure
ventilation, ii) demonstrate that … one wake–sleep cycle (approximately 24 hours), the tracheostomy is removed
(decannulation) and the wound … An occlusive dressing is placed to prevent
air escape during wound healing.
-
psnet.ahrq.gov/node/49437/psn-pdf
March 01, 2004 - complications occur more
commonly in patients with coagulation abnormalities or elevated central venous pressure … catheterization at the internal jugular site, similar to the ones seen in this case,
suggest arterial injury … The timing
of this patient's neurologic deterioration favors an arterial injury. … The key to preventing serious injury to the artery is identifying the arterial puncture prior to dilating … The most definitive
technique is to attach a pressure transducer to the needle and inspect the waveform
-
psnet.ahrq.gov/issue/patient-safety-moving-bar-prison-health-care-standards
August 28, 2024 - September 21, 2005
A randomized trial of a multifactorial strategy to prevent serious fall injuries … Are evidence-based practices associated with effective prevention of hospital-acquired pressure
-
psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - circumstances combine to place the elderly nursing home resident at special risk for preventable drug-related injuries … all of medicine and place older persons residing in nursing homes at substantial risk of iatrogenic injury … We looked at the outcomes on falls, pressure ulcers, and restraint use. … We didn't find it for pressure ulcers. … that many of our readers don't know much about the organizational structure of nursing homes and the pressures
-
psnet.ahrq.gov/issue/nurses-experience-decision-making-processes-missed-nursing-care-qualitative-study
May 11, 2022 - May 19, 2021
Surgeon commitment to trauma care decreases missed injuries. … September 27, 2017
Organisational strategies to implement hospital pressure ulcer prevention
-
psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
April 11, 2018 - April 11, 2018
Early identification and evaluation of severe pressure injuries.
-
psnet.ahrq.gov/issue/keeping-patients-track-preventative-care-during-pandemic
April 11, 2018 - October 10, 2018
Early identification and evaluation of severe pressure injuries.
-
psnet.ahrq.gov/issue/eu-tackle-issue-patient-safety
September 06, 2023 - March 8, 2023
6-PACK programme to decrease fall injuries in acute hospitals: cluster … October 7, 2020
Air pressure: human factors are the key to a safer flight environment
-
psnet.ahrq.gov/issue/optimal-use-telehealth-deliver-safe-patient-care
October 10, 2018 - October 10, 2018
Early identification and evaluation of severe pressure injuries.