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401. Improving patient safety by implementing a standardized and consistent approach to hand-off communication. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-implementing-standardized-and-consistent-approach-hand-communication
     March 01, 2023 - May 28, 2008 The road to zero preventable birth injuries. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

402. 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.

403. Bedside handover: quality improvement strategy to "transform care at the bedside." | PSNet
     psnet.ahrq.gov/issue/bedside-handover-quality-improvement-strategy-transform-care-bedside
     October 27, 2010 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

404. Nursing surveillance: a concept analysis | PSNet
     psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
     May 26, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

405. 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.

406. 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.

407. The nexus of nursing leadership and a culture of safer patient care. | PSNet
     psnet.ahrq.gov/issue/nexus-nursing-leadership-and-culture-safer-patient-care
     January 18, 2018 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

408. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49437/psn-pdf
     March 01, 2004 - complications occur more commonly in patients with coagulation abnormalities or elevated central venous pressure … catheterization at the internal jugular site, similar to the ones seen in this case, suggest arterial injury … The timing of this patient's neurologic deterioration favors an arterial injury. … The key to preventing serious injury to the artery is identifying the arterial puncture prior to dilating … The most definitive technique is to attach a pressure transducer to the needle and inspect the waveform

409. 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

410. 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

411. 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.

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49739/psn-pdf
     August 21, 2015 - 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.

413. Nursing and Patient Safety | PSNet
     psnet.ahrq.gov/primer/nursing-and-patient-safety
     September 07, 2019 - 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.

414. 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.

415. Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study. | PSNet
     psnet.ahrq.gov/issue/strength-safety-measures-introduced-medical-practices-prevent-recurrence-patient-safety
     May 01, 2024 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

416. 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

417. 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.

418. 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

419. 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.

420. 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