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481. Good Catch in the Operating Room | PSNet
     psnet.ahrq.gov/web-mm/good-catch-operating-room
     August 27, 2017 - About halfway through the procedure, the anesthesiologist noticed that the patient's blood pressure was … anesthesiologist administered a bolus of intravenous fluids, but over the next few minutes the patient's blood pressure … The patient required transfusion of multiple units of blood, and fortunately the injury was repaired … first challenge occurred when the anesthesiologist alerted the surgeon during the initial drop in blood pressure … Paige, MD Professor of Clinical Surgery Director of Wound Care LSU Health New Orleans Health Sciences

482. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49606/psn-pdf
     August 01, 2010 - 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 https: … STOP stands for loud snoring, tiredness during the daytime, o bserved apneas, and high blood pressure … Nocturnal continuous positive airway pressure (CPAP) therapy should be instituted 4-6 weeks before planned … position causes significant increases in oxygen consumption, cardiac output, and pulmonary artery pressure

483. Physical Diagnosis: A Lost Art? | PSNet
     psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
     January 17, 2018 - Case & Commentary: Part 1 A 57-year-old male with T8 paraplegia from a remote gunshot wound, hypertension … 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.

484. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
     psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
     September 24, 2024 - Carole Stockmeier:  Patients come to us with faith, hope, and trust that we will restore health and heal wounds … safety culture and found a 37% increase in reporting, and decreases in preventable harm: 39% decrease in injuries … with falls, 37% fewer pressure injuries and a 34% reduction in central line-associated blood stream … For instance, a hospital may focus on eliminating severe pressure injuries as a preventable harm, but

485. Acute Respiratory Arrest in Pregnancy | PSNet
     psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
     August 15, 2018 - Two days prior to admission, the patient presented to the obstetrics clinic with blood pressures (BPs … marked increase in her plasma volume with resultant increase in her preload (increased left atrial pressure … orders for type and frequency of blood tests, fetal monitoring, and surveillance of symptoms and blood pressure … Criteria for E stablishing Severe Preeclampsia.* • Persistent blood pressure above 160/110 mm … Related Resources WebM&M Cases Uterine Artery Injury

486. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33743/psn-pdf
     December 01, 2012 - ], and worse long-term brain function [5]), it is worth thinking about delirium as an "acute brain injury … " similar to other end-organ injuries (e.g., heart attack, acute kidney injury). … As with these other important end-organ injuries, delirium is a clinical event for which prevention and … spontaneous breathing trials (SBT, defined as turning the ventilator settings to continuous positive airway pressure

487. Lapse in Antibiotics Leads to Sepsis | PSNet
     psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
     November 21, 2021 - Upon further evaluation, she was noted to have a rapid heart rate and low blood pressure. … Several hours later, the patient was noted to be lethargic with a low blood pressure. … While the inpatient care team discussed possible causes for her low blood pressure, the microbiology … Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled

488. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49856/psn-pdf
     March 01, 2019 - If there is no cuff leak, it suggests that laryngeal edema or another type of laryngeal injury has reduced … The ICU decided to implement a standardized protocol for positive pressure weaning trials, which also … mechanical ventilation: clinical outcome in patients randomized for a 30-min or 120-min trial with pressure … Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation.

489. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854849/psn-pdf
     October 31, 2023 - On hospital day 2, the primary trauma surgery team ordered magnetic resonance imaging (MRI) of the brain … These studies, completed on hospital day 6, showed no evidence of traumatic or hypoxic brain injury … and no vertebral or ligamentous injury; the radiologist noted “minimal cervical spine epidural blood … capturing data for quality metrics or responding to messages from patients through portals certainly add pressure … professional society educational efforts may be helpful in addressing this generational problem.15 Pressure

490. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49765/psn-pdf
     August 21, 2016 - The patient ultimately regained a pulse but required two vasopressors to maintain her blood pressure … Bedside cannulation of the central circulation for measurement of central venous pressure and for vasopressor … The patient immediately responded, with improved oxygenation and blood pressure. … radiograph provided reassurance that the central line was in the correct position without evidence of lung injury … Relative value of central-venous-pressure monitoring and blood-volume measurement in the management

491. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49859/psn-pdf
     April 01, 2019 - oxygen requirement at home was 2 liters via nasal cannula, and she used a continuous positive airway pressure … Benowitz, MD This case, of a woman who sustained burn injuries from using an electronic cigarette (e-cigarette … Numerous reports have emerged of fires and explosions caused by e- cigarettes, some resulting in severe injuries … In summary, this case describes a serious injury due to use of an e-cigarette, a known ignition source … Electronic cigarette explosion and burn injuries, US emergency departments 2015–2017.

492. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet
     psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
     February 05, 2020 - Nitrous oxide only flows into the oxygen pipeline when the pressure in the nitrous line is higher than … When pressure in the oxygen line drops below that in the nitrous line, it is possible for an outlet to … The pressure in the oxygen and nitrous oxide pipelines as well as in the cylinders mounted on the anesthesia … When the pressure in the oxygen pipeline drops, a gas outlet may begin to deliver a hypoxic gas mixture … WebM&M Cases Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury

493. Delayed Evaluation of Abdominal Pain in an Elderly Patient. | PSNet
     psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
     February 26, 2020 - The patient remained alert and cooperative until 2350H when her blood pressure fell to 90/58. … Nevertheless, every patient deserves to be provided with the best opportunity to survive an illness or injury … that permits all necessary interventions to be provided commensurate with the degree of illness or injury … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery Division of Trauma … 2022 WebM&M Cases Errors in Managing an Open Wound

494. Policies and practices related to the role of board certification and recertification of pediatricians in hospital privileging. | PSNet
     psnet.ahrq.gov/issue/policies-and-practices-related-role-board-certification-and-recertification-pediatricians
     February 03, 2011 - September 29, 2017 Medical injuries among hospitalized children.

495. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33765/psn-pdf
     April 01, 2014 - reason for us to make sure, at least from Leapfrog's spot, that there's a continued laser focus and pressure … We graded every hospital for which there's adequate data on errors, accidents, and injuries. … Then hopefully they will go to the hospital and put some pressure on them to elevate the priority of … How do I protect them from the errors and injuries that are rampant? What can I do better?

496. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851971/psn-pdf
     July 31, 2023 - with factitious disorder consciously and manipulatively (usually surreptitiously) produce illness or injury … advocated by most experienced practitioners.20 Applying cricoid pressure compresses the esophagus and … this communication error because the foreign body likely traversed the gastrointestinal tract without injury … Scand J Trauma Resusc Emerg Med. 2021;29(1):64. [Free full text] 20. … The clinical use of cricoid pressure: first, do no harm. Anesth Analg. 2021;132(1):261-267.

497. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49609/psn-pdf
     October 01, 2010 - Risk factors for falls included patient age, number of comorbidities, having a lower systolic blood pressure … addition, after dialysis sessions, hemodynamic shifts can lead to transient hypotension (low blood pressure … The quality indicators include identification of medical injuries and medical errors. … Falls and fall-related injuries in older dialysis patients.

498. In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring | PSNet
     psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
     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 … 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

499. Remote Patient Monitoring | PSNet
     psnet.ahrq.gov/perspective/remote-patient-monitoring
     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 … 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

500. Cognitive Overload in the ICU | PSNet
     psnet.ahrq.gov/web-mm/cognitive-overload-icu
     June 01, 2005 - The patient ultimately regained a pulse but required two vasopressors to maintain her blood pressure … Bedside cannulation of the central circulation for measurement of central venous pressure and for vasopressor … The patient immediately responded, with improved oxygenation and blood pressure. … radiograph provided reassurance that the central line was in the correct position without evidence of lung injury … Relative value of central-venous-pressure monitoring and blood-volume measurement in the management of