-
psnet.ahrq.gov/periodic-issue/periodic-issue-296
June 30, 2021 - Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired … Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired … situation that, due to failure of reporting and other system issues, enabled over 3,000 diagnostic delay injuries … complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury
-
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.
-
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
-
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
-
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.
-
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
-
psnet.ahrq.gov/issue/risky-business-navigating-shifting-health-care-landscape
December 22, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … June 9, 2021
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
-
psnet.ahrq.gov/issue/developing-culture-collaboration-operating-room-more-effective-communication
June 27, 2018 - 2020
Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries … September 30, 2020
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … October 13, 2021
Trauma Resuscitation Using in situ Simulation Team Training (TRUST) … September 22, 2021
Communication failures contributing to patient injury in anaesthesia
-
psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - elevated creatinine level of 1.8
mg/dL (up from a baseline of 1.1 mg/dL), indicating acute kidney injury … Over this period, his heart rate increased to greater than 120 bpm and his blood pressure was 175/95 … At this point, the patient was given aggressive intravenous antihypertensives (his blood pressure had … Perhaps when acute kidney injury was identified, along with worsening pain
and tachycardia. … include shared decision-making and watchful waiting.(22) Some
emergency medicine physicians argue that pressures
-
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
-
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
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.458_slideshow.ppt
October 01, 2018 - His blood pressure was low (80/50 mm Hg), and he was started on intravenous fluids and broad spectrum … antibiotics with some initial improvement in his symptoms and blood pressure. … Laboratory test results revealed a mildly elevated white count, acute kidney injury, and elevated liver … The patient's blood pressure continued to trend downward to 60/40 mm Hg. … physicians came to believe that a large AMI was the likely explanation for the patient's low blood pressure
-
psnet.ahrq.gov/issue/slow-troubling-death-autopsy
August 19, 2020 - February 17, 2021
Home Health Agencies Failed To Report Over Half of Falls With Major Injury
-
psnet.ahrq.gov/issue/americas-other-drug-problem-copious-prescriptions-hospitalized-elderly
May 12, 2021 - May 12, 2021
Preeminent hospitals penalized over rates of patients’ injuries.
-
psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself
May 11, 2022 - August 12, 2020
Preeminent hospitals penalized over rates of patients’ injuries.
-
psnet.ahrq.gov/issue/bleeding-and-pain-pregnant-woman-louisiana-couldnt-get-answers
January 18, 2023 - January 18, 2023
Preeminent hospitals penalized over rates of patients’ injuries.
-
psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients
May 05, 2021 - September 14, 2016
Preeminent hospitals penalized over rates of patients’ injuries.
-
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
-
psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - blockade, aminoglycosides, or intravenous magnesium; and patients with neurological impairment or injury … 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. … apnea, 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
-
psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - Awareness is also more common during emergency operations for acute trauma. … Trauma anesthesia care has been improving over time; a recent study found that awareness in trauma patients … Her interpretation that the ETT was obstructed by external pressure is very plausible. … Awareness during anesthesia for trauma: has anything changed? … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury