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Showing results for "pressure injury".
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361. Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. | PSNet
     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

362. Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities. | PSNet
     psnet.ahrq.gov/issue/data-driven-quality-improvement-culture-change-and-high-reliability-journey-special-hospital
     March 24, 2021 - Improvements in medication errors and hospital-acquired pressure injuries were observed, but employee

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33589/psn-pdf
     September 15, 2024 - reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures … A classic example is that of the military aircraft carrier: despite significant production pressures … A regional health system in Canada reported a decrease in adverse events such as falls, pressure injuries

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49604/psn-pdf
     June 01, 2010 - catheter, was inserted into the lower spinal cord to remove cerebrospinal fluid—these drains lower pressure … Concerned about causing injury to the patient, he consulted a neurosurgeon who recommended that further … Luckily, the patient suffered no major consequences, but was at risk for spinal cord injury and had … One barrier is "production pressure," which pushes clinicians to keep the patients moving through the … But when things generally go well, and when production pressure is routine, providers can become complacent

365. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
     May 01, 2017 - On examination, he was afebrile but tachycardic (heart rate 110–120 bpm) and hypertensive (blood pressure … an elevated creatinine level of 1.8 mg/dL (up from a baseline of 1.1 mg/dL), indicating acute kidney injury … Diagnostic Delay (4) Over this period, his heart rate increased to greater than 120 bpm and his blood pressure … provider pursued further imaging, she avoided a contrast study because of the patient's acute kidney injury … Delay (8) At this point, the patient was given aggressive intravenous antihypertensives (his blood pressure

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866846/psn-pdf
     September 24, 2024 - culture and found a 37% increase in reporting, and decreases in preventable harm: 39% decrease in injuries … with falls, 37% fewer pressure injuries and a 34% reduction in central line-associated blood stream … For instance, a hospital may focus on eliminating severe pressure injuries as a preventable harm, but

367. Assessing between- and within-hospital differences in patient safety between Medicaid and privately insured hospital patients. | PSNet
     psnet.ahrq.gov/issue/assessing-between-and-within-hospital-differences-patient-safety-between-medicaid-and
     July 31, 2024 - compared with privately insured patients, Medicaid patients experienced significantly higher rates of pressure … injuries, catheter-related infections, and six-out-of-seven surgery-related safety indicators .

368. Breakage of a PICC Line | PSNet
     psnet.ahrq.gov/web-mm/breakage-picc-line
     June 21, 2023 - 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

369. The nurse's experience of decision-making processes in missed nursing care: a qualitative study. | PSNet
     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

370. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? | PSNet
     psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety
     October 23, 2013 - Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure … February 11, 2013 Using root cause analysis to reduce falls with injury in the psychiatric

371. Patient safety in palliative care at the end of life from the perspective of complex thinking. | PSNet
     psnet.ahrq.gov/issue/patient-safety-palliative-care-end-life-perspective-complex-thinking
     October 05, 2022 - care can include inappropriate pain management , preventable hospital (re)admissions, falls, and pressure … injuries .

372. People, processes, health IT and accurate patient identification. | PSNet
     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.

373. Keeping patients on track with preventative care during pandemic. | PSNet
     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.

374. Nursing and Patient Safety | PSNet
     psnet.ahrq.gov/primer/nursing-and-patient-safety
     September 15, 2024 - However, the key findings in a recent integrative review include fewer pressure ulcers and urinary tract … job dissatisfaction and absenteeism for nurses, as well as to medication errors, infections, falls, pressure … injuries, readmissions, and failure to rescue . 10 In addition, If bullying is present within the … and unit culture promote teamwork and lead to nursing job satisfaction that is likely to reduce the pressures … injuries.

375. Becoming a High Reliability Organization. | PSNet
     psnet.ahrq.gov/issue/becoming-high-reliability-organization
     May 04, 2015 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

376. The optimal use of telehealth to deliver safe patient care. | PSNet
     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.

377. EU to tackle issue of patient safety. | PSNet
     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

378. 'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events. | PSNet
     psnet.ahrq.gov/issue/skating-thin-ice-consultant-surgeons-contemporary-experience-adverse-surgical-events
     April 17, 2024 - Production pressures and poor safety culture were among the frequently cited factors predisposing to … August 2, 2015 A randomized trial of a multifactorial strategy to prevent serious fall injuries

379. Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events. | PSNet
     psnet.ahrq.gov/issue/machine-learning-evaluation-inequities-and-disparities-associated-nurse-sensitive-indicator
     July 19, 2023 - Rates of three nurse sensitive indicators - falls , healthcare associated pressure injuries, and healthcare

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33580/psn-pdf
     April 01, 2022 - However, the key findings in a recent integrative review include fewer pressure ulcers and urinary tract … job dissatisfaction and absenteeism for nurses, as well as to medication errors, infections, falls, pressure … injuries, readmissions, and failure to rescue.10 In addition, If bullying is present within the workplace … and unit culture promote teamwork and lead to nursing job satisfaction that is likely to reduce the pressures … injuries.