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361. 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.

362. Situation awareness and the mitigation of risk associated with patient deterioration: a meta-narrative review of theories and models and their relevance to nursing practice. | PSNet
     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

363. Investigation of mental and physical health of nurses associated with errors in clinical practice. | PSNet
     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

364. Psn-Pdf (pdf file)
     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

365. Psn-Pdf (pdf file)
     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.

366. 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

367. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. | PSNet
     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

368. 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

369. '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

370. 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 .

371. Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx (pdf file)
     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

372. 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

373. 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 .

374. Pandemic presents new hurdles, and hope, for people struggling with addiction. | PSNet
     psnet.ahrq.gov/issue/pandemic-presents-new-hurdles-and-hope-people-struggling-addiction
     September 01, 2016 - June 27, 2018 More than 750 hospitals face Medicare crackdown on patient injuries. … August 12, 2020 Preeminent hospitals penalized over rates of patients’ injuries.

375. 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

376. How real-time data can change the patient safety game. | PSNet
     psnet.ahrq.gov/issue/how-real-time-data-can-change-patient-safety-game
     July 07, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

377. 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

378. 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

379. 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.

380. Optimizing medication safety in the home. | PSNet
     psnet.ahrq.gov/issue/optimizing-medication-safety-home
     August 24, 2015 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.