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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.
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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.
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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.
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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
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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
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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
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psnet.ahrq.gov/issue/design-and-implementation-infection-prevention-program-risk-management-managing-high-level
December 18, 2014 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - The cause of death was documented as hip trauma from the fall at the nursing home. … , 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 … to risk reduction for this resident might have been to evaluate and monitor lying and standing blood pressures … Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older
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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
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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
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - 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.
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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.
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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.
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - technical aspects of anesthetic management (e.g., airway intubation, drug distribution and uptake, risk of pressure … injury), but poorly controlled medical comorbidities are probably the most important factors increasing … Nocturnal continuous positive airway pressure (CPAP) therapy should be instituted 4-6 weeks before planned … November 15, 2011
A randomized trial of a multifactorial strategy to prevent serious fall injuries … Related Resources
WebM&M Cases
Errors in Managing an Open Wound
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - [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
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psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
August 16, 2023 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - 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 ] Xuan Q, Lyu Z, Chen Q, et al. … Continuous positive airway pressure versus high-flow nasal cannula oxygen therapy for acute hypoxemic
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psnet.ahrq.gov/issue/registration-associated-patient-misidentification-academic-medical-center-causes-and
September 02, 2020 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/issue/sustaining-improvement-hospital-wide-initiative-patient-safety-and-quality-systematic-scoping
September 01, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.