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Showing results for "pressure injury".
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401. Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. | PSNet
     psnet.ahrq.gov/issue/toward-zero-harm-mackenzie-healths-journey-toward-becoming-high-reliability-organization-and
     September 14, 2022 - reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure … injuries and healthcare-acquired infections.

402. Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients? | PSNet
     psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
     December 14, 2022 - reports involved interunit/department/team transfers and the majority (69%) of incidents were related to pressure … injuries, falls, medication, and documentation errors.

403. Examining the meaning of the language used to communicate the nursing hand-off. | PSNet
     psnet.ahrq.gov/issue/examining-meaning-language-used-communicate-nursing-hand
     July 07, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

404. Preventable and mitigable adverse events in cancer care: measuring risk and harm across the continuum. | PSNet
     psnet.ahrq.gov/issue/preventable-and-mitigable-adverse-events-cancer-care-measuring-risk-and-harm-across-continuum
     July 19, 2017 - Adverse events included medication errors and hospital-acquired conditions , such as pressure ulcers … September 20, 2017 Injuries before and after diagnosis of cancer: nationwide register

405. The Forgotten Line | PSNet
     psnet.ahrq.gov/web-mm/forgotten-line
     March 11, 2011 - [CVP] above atmospheric pressure). … They should be instructed to perform a Valsalva maneuver or forced expiration (where atmospheric pressure … is less than intrathoracic pressure) during removal, and removal should be followed by applying pressure … sheet or discharge checklist), or a culture that suppresses "unnecessary questions" because of time pressure … Developing policies, training, and a safety culture that reduce the risk of injury by making it easier

406. Breathe Easy: Safe Tracheostomy Management | PSNet
     psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
     June 07, 2023 - Tracheostomy 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.

407. What can safety cases offer for patient safety? A multisite case study. | PSNet
     psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study
     February 07, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

408. Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. | PSNet
     psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events
     April 17, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

409. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
     July 01, 2003 - At this time, the patient’s blood pressure was 90/palpable, heart rate was 40 and an O2 saturation was … her preference to avoid invasive ventilation, she was started on noninvasive bi-level positive airway pressure … with uncertain outcomes i.e., successful cardiac resuscitation with resultant severe anoxic brain injury

410. PowerPoint Presentation (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
     February 01, 2003 - Neuromuscular blockade overdose Aminoglycosides or intravenous magnesium Neurological impairment or injury … error in drug administration is recognized immediately after injection: Stop the IV If there is blood pressure … apnea, muscle weakness, or visual disturbances Extreme or unexpected increase or decrease in blood pressure

411. Nurses' use of computerized clinical guidelines to improve patient safety in hospitals. | PSNet
     psnet.ahrq.gov/issue/nurses-use-computerized-clinical-guidelines-improve-patient-safety-hospitals
     June 06, 2018 - February 14, 2024 A randomized trial of a multifactorial strategy to prevent serious fall injuries … May 29, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

412. An intervention to enhance nursing staff teamwork and engagement. | PSNet
     psnet.ahrq.gov/issue/intervention-enhance-nursing-staff-teamwork-and-engagement
     June 21, 2010 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

413. Nurses discuss bedside handover and using written handover sheets. | PSNet
     psnet.ahrq.gov/issue/nurses-discuss-bedside-handover-and-using-written-handover-sheets
     January 24, 2018 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

414. Young surgeons on speaking up: when and how surgical trainees voice concerns about supervisors' clinical decisions. | PSNet
     psnet.ahrq.gov/issue/young-surgeons-speaking-when-and-how-surgical-trainees-voice-concerns-about-supervisors
     April 13, 2017 - April 13, 2017 A randomized trial of a multifactorial strategy to prevent serious fall injuries … October 13, 2018 Fake it 'til you make it: pressures to measure up in surgical training

415. In Conversation With… Nicholas G. Castle, MHA, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
     August 01, 2012 - 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 … 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 … resident-months, of which 40% were considered preventable.( 7 ) Errors associated with preventable drug-related injuries

416. Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study. | PSNet
     psnet.ahrq.gov/issue/mortality-and-risk-factors-associated-misdiagnosis-acute-aortic-syndrome-ontario-canada
     September 23, 2020 - March 5, 2025 A randomized trial of a multifactorial strategy to prevent serious fall injuries … May 29, 2024 WebM&M Cases Under Pressure: Delayed Diagnosis

417. Crossover of the patient satisfaction surveys, adverse events and patient complaints for continuous improvement in radiotherapy department. | PSNet
     psnet.ahrq.gov/issue/crossover-patient-satisfaction-surveys-adverse-events-and-patient-complaints-continuous
     July 27, 2022 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

418. Factor structure and construct validity of a hospital survey on patient safety culture using exploratory factor analysis. | PSNet
     psnet.ahrq.gov/issue/factor-structure-and-construct-validity-hospital-survey-patient-safety-culture-using
     June 29, 2022 - May 8, 2017 A randomized trial of a multifactorial strategy to prevent serious fall injuries … February 22, 2023 Barriers and facilitators to reporting medical device-related pressure

419. Nursing bedside clinical handover—an integrated review of issues and tools. | PSNet
     psnet.ahrq.gov/issue/nursing-bedside-clinical-handover-integrated-review-issues-and-tools
     July 07, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

420. A mixed-methods systematic review of interventions to address incivility in nursing. | PSNet
     psnet.ahrq.gov/issue/mixed-methods-systematic-review-interventions-address-incivility-nursing
     December 02, 2020 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.