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  1. 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
  2. psnet.ahrq.gov/issue/optimizing-medication-safety-home
    August 24, 2015 - Root cause analysis to identify contributing factors for the development of hospital acquired pressureinjuries.
  3. psnet.ahrq.gov/issue/redesigning-hospital-alarms-patient-safety-alarmed-and-potentially-dangerous
    December 12, 2018 - Related Resources From the Same Author(s) Success in hospital-acquired pressure … December 12, 2018 Differences in the reporting of care-related patient injuries to existing
  4. Psn-Pdf (pdf file)

    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
  5. 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 pressureinjuries, catheter-related infections, and six-out-of-seven surgery-related safety indicators .
  6. psnet.ahrq.gov/issue/review-bringing-patient-safety-forefront-through-structured-computerisation-during-clinical
    January 13, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressureinjuries and medication administration errors: an integrative review.
  7. psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
    September 18, 2024 - Over this period, his heart rate increased to greater than 120 bpm and his blood pressure was 175/95 … At this point, the patient was given aggressive intravenous antihypertensives (his blood pressure had … Perhaps when acute kidney injury was identified, along with worsening pain and tachycardia. … include shared decision-making and watchful waiting.( 22 ) Some emergency medicine physicians argue that pressures … Diagnostic error in the emergency department: follow up of patients with minor trauma
  8. psnet.ahrq.gov/issue/dashboard-design-identify-and-balance-competing-risk-multiple-hospital-acquired-conditions
    December 16, 2020 - management combining the risks of multiple conditions (catheter-associated urinary tract infections, pressureinjuries, and falls).
  9. 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
  10. psnet.ahrq.gov/issue/patients-right-safety-improving-quality-care-through-litigation-against-hospitals
    February 17, 2011 - interventions coupled with the 100,000 Lives Campaign , suggesting the other half should feel the pressure … February 17, 2011 A randomized trial of a multifactorial strategy to prevent serious fall injuries
  11. 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
  12. 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
  13. 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
  14. Psn-Pdf (pdf file)

    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
  15. psnet.ahrq.gov/web-mm/overdose-oxygen
    August 02, 2023 - Oxygen tensions above about 50 mm Hg (saturation above about 85%) will protect patients from hypoxic injury … 2019 A randomized trial of a multifactorial strategy to prevent serious fall injuries … October 6, 2021 Implementation of the World Health Organization Trauma Care Checklist … mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma … March 27, 2024 WebM&M Cases Uterine Artery Injury
  16. 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
  17. psnet.ahrq.gov/primer/patient-safety-indicators
    September 07, 2019 - which Brennan and colleagues defined in the Harvard Medical Practice Study in New York State as “an injury … Thoracic Surgeons offers patient safety indicators for adult cardiac surgery, such as deep sternal woundinjuries) and hospital acquired infections (CLABSI, CAUTI). … dehiscence, and obstetric trauma. … deaths due to health care-associated venous thromboembolism, sepsis, or patient falls; in-hospital pressure
  18. psnet.ahrq.gov/issue/occurrence-no-harm-incidents-and-adverse-events-hospitalized-patients-ischemic-stroke-or-tia
    August 05, 2020 - The most common preventable events were medication events , pressure injuries, and healthcare-associated
  19. psnet.ahrq.gov/periodic-issue/weekly-resource-0
    October 30, 2024 - Organizational factors, including workload and time pressure, were identified in 93% of studies. … in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. … 2024 A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury … A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without … The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults
  20. 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

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