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Showing results for "pressure injury".
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461. Periodic Issue | PSNet
     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

462. 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.

463. 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

464. 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

465. 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.

466. 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

467. Risky Business: Navigating a Shifting Health Care Landscape. | PSNet
     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.

468. Developing a culture of collaboration in the operating room: more than effective communication. | PSNet
     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

469. Psn-Pdf (pdf file)
     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

470. 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

471. 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

472. Spotlight (ppt file)
     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

473. The slow, troubling death of the autopsy. | PSNet
     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

474. 'America's other drug problem': copious prescriptions for hospitalized elderly. | PSNet
     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.

475. ‘You’re going to release him when he was hurting himself?’ | PSNet
     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.

476. Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers. | PSNet
     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.

477. Addiction treatment providers in Pa. face little state scrutiny despite harm to clients. | PSNet
     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.

478. 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

479. Psn-Pdf (pdf file)
     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

480. Intraoperative Awareness during Rhinoplasty | PSNet
     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