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641. In Conversation with... Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ Population | PSNet
     psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patient-safety-concerns-and-lgbtq-population
     February 01, 2023 - In these cases, easily managed health needs like high blood pressure or diabetes can progress to acute … People may go to a provider because they have an injury or concern, and providers can only focus on their … There is also that trauma of accessing care and feeling that bias and stigma, which can prevent patients … I am trans, but I also have high blood pressure and high cholesterol. … We just want to be seen as humans, so that we can get our blood pressure managed on a regular basis.

642. 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

643. 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

644. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49779/psn-pdf
     January 01, 2017 - these failures are more likely when staff are working under high levels of stress, workload, or time pressure … Injuries are caused by a lack of differentiation between the use of infusion devices in hospitals and

645. 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

646. In Conversation With... Freya Spielberg, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
     September 28, 2022 - A big step was just educating people that, in fact, they have high blood pressure and how they can take … As part of this education, the community health worker would give a patient a blood pressure monitor … so they could take their own blood pressure at different times during the day and see for themselves … that since hypertension is such a huge issue in these populations, everybody should have a home blood pressure … AHRQ’s broad definition of patient safety includes “prevention of diagnostic errors, medical errors, injury

647. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49744/psn-pdf
     October 01, 2015 - The Case A 47-year-old man with paraplegia (secondary to a gunshot wound) and a history of polysubstance … Unfortunately, his cardiac arrest led to an anoxic brain injury, and he remained in a vegetative state … 11  Laboratory test(s) 12  Laboratory value(s)/result(s) 13  Vital signs: height, weight, blood pressure

648. 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

649. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
     January 01, 2024 - Due to the delayed diagnosis, the patient suffered permanent brain injury requiring around-the-clock … These barriers include professional hierarchy, time pressure, challenging workloads, and inadequate structures

650. 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

651. 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

652. 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.

653. 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.

654. 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?

655. 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.

656. 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.

657. 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.

658. 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

659. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/853774/psn-pdf
     September 27, 2023 - Her vital signs included blood pressure 110/73 mmHg, heart rate 104 beats per minute, respirations 16 … 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

660. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49411/psn-pdf
     July 01, 2003 - On physical examination, her blood pressure was 145/85, pulse 85, oxygen saturation of 94%, with a respiratory … At this point, the patient’s blood pressure was 90/palpable with a heart rate of 40 and an O2 saturation … references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references level positive airway pressure … with uncertain outcomes, such as successful cardiac resuscitation with resultant severe anoxic brain injury