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581. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-375
     December 14, 2022 - The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated … The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated … uneventful and intraoperative neuromonitoring was used to help prevent spinal cord and peripheral nerve injury

582. 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

583. 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

584. Managing Ascites: Hazards of Fluid Removal | PSNet
     psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
     June 01, 2018 - This is because the risk of developing acute kidney injury and/or hepatorenal syndrome is highest in … reduction in right atrial pressure. … The vasodilatation that occurs in the splanchnic bed leads to a lowering of mean arterial pressure and … Large volume paracentesis is generally safe, but blood pressure may fall and require treatment. … Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma

585. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-432
     March 27, 2024 - demands during the crisis to affect falls, medication safety, healthcare associated infections, and pressure … injuries. … This commentary highlights the challenges in managing blunt trauma in actively bleeding patients with … [ATLS], Massive Transfusion Protocol [MTP]) to protect against misadventures in the trauma bay. … WebM&M Cases Spotlight Case Uterine Artery Injury during Cesarean Delivery Leads to Cardiac

586. Healthcare 411: Patient Safety Organizations Proposed Regulation. | PSNet
     psnet.ahrq.gov/issue/healthcare-411-patient-safety-organizations-proposed-regulation
     April 25, 2018 - July 1, 2022 Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting … January 17, 2018 Pressure Injury Prevention in Hospitals Training Program.

587. Avoiding care during the pandemic could mean life or death. | PSNet
     psnet.ahrq.gov/issue/avoiding-care-during-pandemic-could-mean-life-or-death
     April 09, 2014 - August 26, 2020 Preeminent hospitals penalized over rates of patients’ injuries.

588. Do no unconscious harm. | PSNet
     psnet.ahrq.gov/issue/do-no-unconscious-harm
     October 14, 2020 - January 5, 2012 The nurse's role in the causation of compensable injury.

589. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet
     psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
     August 14, 2024 - prevent the development of hematoma after ACSS. 18 Additionally, maneuvers that transiently raise venous pressure … Early identification is crucial, as airway obstruction may evolve rapidly and hypoxic brain injury follows … C lear steri-strips and pull suture O pen wound – cut skin and platysma stitches O pen wound – … Hypoxic brain injury occurs rapidly after airway obstruction, and prompt recognition and management of … Perforation March 15, 2023 WebM&M Cases Under Pressure

590. One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. | PSNet
     psnet.ahrq.gov/issue/one-size-fits-all-mixed-methods-evaluation-impact-100-single-room-accommodation-staff-and
     July 01, 2016 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … May 11, 2019 A randomized trial of a multifactorial strategy to prevent serious fall injuries

591. 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

592. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
     October 01, 2010 - Falls and fall-related injuries in older dialysis patients. … dialysis centers include: Patient age Total number of co-morbidities Predialysis systolic blood pressure … Falls and fall-related injuries in older dialysis patients. Clin J Am Soc Nephrol. 2006;1:1197-1204. … Falls and fall-related injuries in older dialysis patients. Clin J Am Soc Nephrol. 2006;1:1197-1204.

593. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-449
     July 10, 2024 - Rates of three nurse sensitive indicators - falls, healthcare associated pressure injuries, and healthcare … Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints … positioning, and the importance of early identification of compartment syndrome to prevent permanent injury

594. 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

595. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49679/psn-pdf
     March 01, 2013 - demonstrates that misuse of an unfamiliar medical device can lead to potentially devastating patient injury … and secondary emotional trauma for the involved health care professional. … In one hospital, direct observation of 50 nurses flushing a CVC with a positive pressure adapter revealed … The guidance is intended to improve the usability of medical devices to reduce user error, injuries … Medical device related deaths and injuries should be reported to the FDA.

596. 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.

597. 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.

598. The Unfamiliar Catheter | PSNet
     psnet.ahrq.gov/web-mm/unfamiliar-catheter
     November 01, 2006 - demonstrates that misuse of an unfamiliar medical device can lead to potentially devastating patient injury … and secondary emotional trauma for the involved health care professional. … In one hospital, direct observation of 50 nurses flushing a CVC with a positive pressure adapter revealed … Take-Home Points Unfamiliarity with a CVC can lead to a serious patient injury and have a profound … Medical device related deaths and injuries should be reported to the FDA .

599. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841566/psn-pdf
     December 14, 2022 - Falls and pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing … major injury increase by 17% and pressure ulcers increase by over 40%. … healthcare- acquired infections, complications, medication safety, safety of the EMR, patient falls with injury … , and pressure injuries. … Did you take someone's blood pressure?

600. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841139/psn-pdf
     December 14, 2022 - 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 … interpreter), the physician’s error should be fully disclosed, and appropriate compensation for her dental injury … Production pressure, medical errors, and the pre-anesthesia checkout. … Production pressures among anaesthesiologists in Singapore. Singapore Med J. 2018;59(5):271-278.