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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
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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.
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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.
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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
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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
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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
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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
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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
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psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting
May 20, 2009 - The most common adverse events reported were pressure ulcers and fall-related injuries or deaths .
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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
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - These include injury to
vessels or organs during insertion, catheter migration or malposition with extravasation … The study found that the most common
complications were wound oozing, phlebitis, occlusion, infection … It seems prudent to avoid flushing catheters under high pressure
or using small syringes. … PICC complications include injury to other vessels or organs during insertion, catheter migration or … Caregivers should be warned against flushing PICCs with small-volume syringes or with too much
pressure
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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
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - one of my favorites,
because it is a simple and direct maneuver that eliminates the risk of serious trauma … from falls,
restraints may also cause injury. … serious problem in the
hospital, putting patients at risk for many other problems, including delirium, pressure … hip fractures,(5) but this represents a change in emphasis from fall prevention to
attenuation of trauma … Mechanical restraint use and fall related injuries among residents of
skilled nursing facilities.
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - SPOTLIGHT CASE
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and … Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. … Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. … Oxygen saturation <93% Heart rate >110 or <50 beats/min (bpm) Respiratory rate >24 or <10/minute Blood pressure … Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy.
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psnet.ahrq.gov/issue/situation-awareness-and-mitigation-risk-associated-patient-deterioration-meta-narrative
December 08, 2021 - August 3, 2022
Barriers and facilitators to reporting medical device-related pressure … April 29, 2020
A critical review: moral injury in nurses in the aftermath of a patient
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psnet.ahrq.gov/issue/investigation-mental-and-physical-health-nurses-associated-errors-clinical-practice
September 21, 2022 - Related Resources
Barriers and facilitators to reporting medical device-related pressure … Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - 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 … artery aneurysms. 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/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.
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psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
January 15, 2020 - July 31, 2019
Early identification and evaluation of severe pressure injuries.
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - • The cause of death was documented as hip trauma from the fall at the
nursing home.
7
Case … ,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 whether she also may have suffered a drop in her blood
pressure and experienced lightheadedness … risk reduction for this resident might have
been:
– to evaluate and monitor lying and standing blood pressures