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Showing results for "pressure injury".
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441. Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia. | PSNet
     psnet.ahrq.gov/issue/identifying-safety-practices-perceived-low-value-exploratory-survey-healthcare-staff-united
     February 03, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

442. Adverse events and their contributors among older adults during skilled nursing stays for rehabilitation: a scoping review. | PSNet
     psnet.ahrq.gov/issue/adverse-events-and-their-contributors-among-older-adults-during-skilled-nursing-stays
     February 17, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

443. Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals. | PSNet
     psnet.ahrq.gov/issue/visitor-behaviors-can-influence-risk-patient-harm-analysis-patient-safety-reports-92
     September 01, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

444. Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands. | PSNet
     psnet.ahrq.gov/issue/examining-causes-and-prevention-strategies-adverse-events-deceased-hospital-patients
     June 08, 2022 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

445. Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation. | PSNet
     psnet.ahrq.gov/issue/outsourcing-health-care-services-private-sector-and-treatable-mortality-rates-england-2013-20
     October 21, 2020 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

446. Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial. | PSNet
     psnet.ahrq.gov/issue/effect-systematic-physician-cross-checking-reducing-adverse-events-emergency-department
     November 29, 2023 - In emergency departments (EDs), high medical acuity , incomplete information, and productivity pressures … February 12, 2020 Prevention of fall-related injuries in long-term care: a randomized

447. Hidden Mystery | PSNet
     psnet.ahrq.gov/web-mm/hidden-mystery
     December 01, 2011 - care and prevention of pressure ulcers, respiratory and ventilator support, and correct administration … The indeterminate abdominal sonogram in multisystem blunt trauma. … The emerging role of bedside ultrasonography in trauma care. … The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. … the Same Author(s) WebM&M Cases Missing the Point—Eye Injury

448. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet
     psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
     January 29, 2021 - The patient did not suffer permanent neurological injury from the prolonged hypoxemia, but she did require … Health care providers are frequently under time pressure to bring the next patient to the operating room … Production pressure, medical errors, and the pre-anesthesia checkout. … Production pressures among anaesthesiologists in Singapore. … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

449. Tacit Handover, Overt Mishap | PSNet
     psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
     August 01, 2006 - 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 to … 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

450. High Reliability | PSNet
     psnet.ahrq.gov/primer/high-reliability
     January 29, 2020 - reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures … A classic example is that of the military aircraft carrier: despite significant production pressures … A regional health system in Canada reported a decrease in adverse events such as falls, pressure injuries

451. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet
     psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
     March 18, 2020 - Anesthetic factors such as difficult intubation , light anesthesia, prolonged surgery duration, or positive pressure … contents in the mouth or airway, other signs of aspiration include persistent hypoxia, high airway pressures … Positive pressure mask ventilation for an aspirating patient is not ideal due to the risk of pushing … July 31, 2024 WebM&M Cases Uterine Artery Injury … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

452. An organizational assessment of disruptive clinician behavior: findings and implications. | PSNet
     psnet.ahrq.gov/issue/organizational-assessment-disruptive-clinician-behavior-findings-and-implications
     September 09, 2015 - Production pressures and system inefficiencies were identified as a principal factor contributing to … March 5, 2014 Massachusetts Alliance for Communication and Resolution Following Medical Injury

453. Unexplained Apnea Under Anesthesia | PSNet
     psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
     December 01, 2005 - disabling adverse events, 45% of those events were caused by errors.( 6 ) In a large insurer’s study, injuries … Poor system design also makes errors difficult to intercept before injury occurs. … muscle weakness, and visual disturbances Extreme or unexpected increase or decrease in blood pressure … carrying the drug Attempt to aspirate or drain the IV tubing to point of injection If there is blood pressure … samples for ABG and serum electrolyte levels Conduct a neurological examination to exclude focal CNS injury

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49516/psn-pdf
     August 01, 2006 - Case & Commentary: Part 1 A 57-year-old male with T8 paraplegia from a remote gunshot wound, hypertension … recorded as follows:            General: Mild respiratory distress with audible wheezing Vitals: Blood pressure … In one study, 90% of patients expected their blood pressure to be measured and their heart, lungs, abdomen … One of us (G.R.T.) has seen a patient with spinal cord injury who was transferred from an outside hospital … Clinical assessment of central venous pressure in the critically ill.

455. Visitor restrictions during the COVID-19 pandemic and increased falls with harm at a Canadian hospital: an exploratory study. | PSNet
     psnet.ahrq.gov/issue/visitor-restrictions-during-covid-19-pandemic-and-increased-falls-harm-canadian-hospital
     June 05, 2013 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

456. Inadequate hand-off communication. | PSNet
     psnet.ahrq.gov/issue/inadequate-hand-communication
     April 02, 2015 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

457. The incidence and nature of in-hospital adverse events: a systematic review. | PSNet
     psnet.ahrq.gov/issue/incidence-and-nature-hospital-adverse-events-systematic-review
     March 24, 2011 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

458. If You Say So: Taking a Syringe at Face Value in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
     January 01, 2015 - Over the next few minutes, the patient's blood pressure skyrocketed to 250/135 mm Hg. … contributors to error in the current case are situational and likely include organizational culture and social pressure … toxic cultures that inhibit communication and assertion of concerns and that exert deep and pervasive pressure … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

459. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation | PSNet
     psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
     June 28, 2023 - apparently due to miscommunication at change-of-shift, led to more serious consequences from his iatrogenic injury … facial or skull base fractures; head, neck, or esophageal neoplasms; recent upper GI surgery; esophageal trauma … injuries in the intensive care unit showed that 1.6% were caused by NGTs. 13 In a retrospective study … Each attempt at NGT placement presents a risk of complications such as esophageal trauma, tracheal placement … Nursing care guidelines for reducing hospital-acquired nasogastric tube-related pressure injuries.

460. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845472/psn-pdf
     March 15, 2023 - We monitored the blood pressures of home peritoneal dialysis patients. … We knew their trends and that some of them had typically higher blood pressures and some of them had … typically lower blood pressures, so we created individual thresholds.1,3,4 Sarah Mossburg: It sounds … Historically, these are acute problems that arise where there is illness or injury. … We knew there were hospital capacity problems and a lot of different pressures and stakeholders that