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41. Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. | PSNet
    psnet.ahrq.gov/issue/improvement-patient-safety-may-precede-policy-changes-trends-patient-safety-indicators-united
    November 01, 2017 - The authors discuss major CMS payment policy changes and their intersection with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the decline trends in PSI rates … August 10, 2022 Complexity bias in the prevention of iatrogenic injury: why specific … May 13, 2020 Assessment of nursing home reporting of major injury falls for quality measurement

42. Social capital and knowledge sharing: effects on patient safety. | PSNet
    psnet.ahrq.gov/issue/social-capital-and-knowledge-sharing-effects-patient-safety
    September 15, 2011 - Related Resources From the Same Author(s) System approach to prevent common bile duct injury … September 15, 2011 Surgeon commitment to trauma care decreases missed injuries. … June 15, 2012 Interactive effects of nurse-experienced time pressure and burnout on patient … January 9, 2011 The culture of a trauma team in relation to human factors.

43. An innovative mobile approach for patient safety services: the case of a Taiwan health care provider. | PSNet
    psnet.ahrq.gov/issue/innovative-mobile-approach-patient-safety-services-case-taiwan-health-care-provider
    September 27, 2017 - Citation Related Resources From the Same Author(s) Surgeon commitment to trauma … care decreases missed injuries. … June 15, 2012 System approach to prevent common bile duct injury and enhance performance … August 30, 2023 Interactive effects of nurse-experienced time pressure and burnout on

44. Haste Makes Care Unsafe | PSNet
    psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - Benefits include measurement of important parameters (e.g., PA occlusion wedge pressure [an indirect … indication of left atrial pressure, a surrogate for left ventricular function], cardiac output, and mixed … hurry-up" situation should be a red flag that leads to recognition of the danger of such production pressures … While it is tempting to look at a case like this and focus only on understaffing or production pressures … Under all perioperative circumstances, but particularly with dangerously increased production pressure

45. Misconnection Leading to Arterial Thrombosis | PSNet
    psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
    January 29, 2021 - and procalcitonin levels were elevated, serum creatinine was 1.5 mg/dL (consistent with acute kidney injury … when the patient is hypotensive. 7,8,9 Arterial injection of drugs can cause ischemia by direct vessel injury … blood pressure.  … Display arterial and central venous pressures on the monitor Displaying the pressure measured at the … Injection injury of an aberrant superficial radial artery requiring surgical intervention.  

46. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet
    psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
    September 25, 2024 - The required insufflation leads to an increase in peak inspiratory pressures, and this increase is more … pronounced during dilation as the balloon pressure increases tracheal stress. … Patient death or serious injury associated with intravascular air embolism that occurs while being cared … If endoscopy is utilized, decreased insufflation and lower dilation pressures may be necessary to avoid … Technical steps like using appropriate monitoring, minimizing insufflation and dilation pressures to

47. The Hidden Danger of Unseen Intravenous Catheters | PSNet
    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - efflux of solutions from a vessel into the surrounding tissue during an infusion” and may cause grave injury … Outcomes and management of peripheral intravenous infiltration injuries. Hand (NY) . … Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. … June 2, 2015 Implementation of the World Health Organization Trauma Care Checklist Program … WebM&M Cases Intraosseous Line Extravasation in a Pediatric Trauma

48. The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet
    psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
    July 10, 2024 - September 27, 2016 Towards international consensus on patient harm: perspectives on pressure … injury policy. … August 7, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

49. Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors | PSNet
    psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
    May 31, 2023 - High risk of errors, preventable death : Multidisciplinary trauma teams face tremendous time pressures … , and specialty situations (neurotrauma, burns, spinal cord injury, and orthopedic trauma). … For example, prompts might remind staff working with a patient with abnormally low blood pressure to … The program had a particularly large impact on the use of pressure dressings to control hemorrhage (p … Missed injuries in a level I trauma center. J Trauma. 2002 Apr;52(4):715-9. 

50. The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England. | PSNet
    psnet.ahrq.gov/issue/effect-providing-staff-training-and-enhanced-support-care-homes-care-processes-safety-climate
    September 15, 2021 - Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in … After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced. … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … See More About The Topic Long-Term Care Quality and Safety Professionals Geriatrics Pressure

51. Barriers to and facilitators of bedside nursing handover: a systematic review and meta-synthesis. | PSNet
    psnet.ahrq.gov/issue/barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-meta-synthesis
    August 25, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

52. Nurse burnout syndrome and work environment impact patient safety grade. | PSNet
    psnet.ahrq.gov/issue/nurse-burnout-syndrome-and-work-environment-impact-patient-safety-grade
    August 04, 2021 - August 19, 2020 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury

53. Intentional rounding—an integrative literature review. | PSNet
    psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review
    October 08, 2016 - The authors explore areas of impact, including patient satisfaction, falls , and hospital-acquired pressure … From the Same Author(s) Towards international consensus on patient harm: perspectives on pressure … injury policy.

54. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. | PSNet
    psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
    January 29, 2021 - chest wall muscles can create much higher negative intrathoracic pressures than those of elderly patients … Succinylcholine is contraindicated in patients with stroke, spinal cord injury, burns, or myotonic dystrophy … inadequate resources such as the broken drug refrigerator otherwise could have led to irreversible injury … Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers … Negative-pressure pulmonary edema.

55. Patient safety indicators during the initial COVID-19 pandemic surge in the United States. | PSNet
    psnet.ahrq.gov/issue/patient-safety-indicators-during-initial-covid-19-pandemic-surge-united-states
    August 03, 2022 - September 1, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … About The Topic Hospitals Public Health Infectious Diseases Medical Complications Pressure

56. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet
    psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
    January 29, 2021 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … ; this change was associated with decreased risk of motor vehicle crash involvement and needlestick injury … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours? … Effects of coffee on ambulatory blood pressure in older men and women: a randomized controlled trial.

57. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. | PSNet
    psnet.ahrq.gov/issue/delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations
    March 25, 2020 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … March 18, 2020 Applying modern error theory to the problem of missed injuries in trauma

58. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - 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 wound … injuries) 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

59. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement | PSNet
    psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
    July 01, 2004 - improved functional independence at 4 and 12 months.( 12-14 ) Hip fracture is a common and serious injury … , which in turn increases the risk of delirium, thromboembolism, pneumonia, pressure ulcers, and significant … Injury. 2018;49:1458-1460. [go to PubMed] 2. Cummings SR, Black DM, Rubin SM. … J Orthop Trauma. 2006;20:172-180. [go to PubMed] 12. … J Orthop Trauma. 2014;28:e49-e55.

60. Adverse effects of the Medicare PSI-90 hospital penalty system on revenue-neutral hospital-acquired conditions. | PSNet
    psnet.ahrq.gov/issue/adverse-effects-medicare-psi-90-hospital-penalty-system-revenue-neutral-hospital-acquired
    October 30, 2024 - Overall, HAC rates declined over the 2 years following implementation of the program, with only rates of pressure … Are evidence-based practices associated with effective prevention of hospital-acquired pressure … December 21, 2017 Complexity bias in the prevention of iatrogenic injury: why specific