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661. 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

662. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet
     psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
     August 31, 2022 - If he or she described a ‘wound infection in a plastic surgery patient,’ for example, this would have … Burnout Physician burnout (also referred to as “moral injury”) is an ongoing topic of discussion in medicine … survey of subspecialty surgeons: “while EGS surgeons appear to meet [a clinical] need and relieve some pressure … Health   Garth Utter, MD, MSc Professor of Surgery Department of Surgery, Division of Trauma UC Davis … Journal of Trauma and Acute Care Surgery . 2018 July;85(1):208-214.

663. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49726/psn-pdf
     March 01, 2015 - as a sentinel event—an unexpected occurrence involving death or serious physical or psychological injuries … markings, surgeon fatigue, numerous surgeons, multiple procedures on the same patient, atypical time pressures

664. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49550/psn-pdf
     December 01, 2007 - preoperative period but suffered a pulseless electrical activity arrest in the operating room at the time of wound … based on 1997 data from the National Inpatient Sample Excludes patients with any code for cancer, trauma … Excludes patients with any diagnosis code for drug dependence, abuse of drugs, or self-inflicted injury … Decubitus ulcer Pressure sores in patients hospitalized for 4 days or longer Discharges with ICD … diagnosis among all surgical discharges Excludes patients who have principal diagnosis codes for trauma

665. 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

666. 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.

667. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet
     psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
     August 01, 2009 - She was afebrile, tachycardic (120 beats per minute), with a normal blood pressure (109/51) and excellent … ulceration or necrosis, chronic gastric irritation leading to gastrointestinal bleeding from gastritis or pressure … approximately 30 to 35 cm allows repositioning of misplaced tubes and can potentially prevent pulmonary injury

668. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50614/psn-pdf
     October 30, 2019 - lines, you don't have to go anywhere near the great vessels of the neck or the chest, so you avoid injury … You avoid injury to the lung—that dreaded complication of pneumothorax. … You just put pressure at that site in the arm and compress the vessel against the underlying humerus … Think about it: when you insert a PICC, your needle causes endothelial injury, in a patient that's hypercoaguable

669. 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

670. 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

671. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
     January 01, 2023 - by ambulance to a tertiary Emergency Department (ED) from a referring hospital due to a left leg injury … left hip flexed with significant tenderness on examination, but there were no other obvious signs of trauma … during a diagnostic or therapeutic procedure.”4,5 • Sedation can also ameliorate the psychological trauma … Patients often require assistance in maintaining a patent airway, and positive pressure ventilation … • Blood pressure should be measured frequently, and the electrocardiogram, heart rate, respiratory

672. 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.

673. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49400/psn-pdf
     May 01, 2003 - A full code ensued and after a brief time, the patient was stabilized with a blood pressure of 95/55 … or more risk factors identified only one patient with a DVT.(9) A retrospective study of pediatric trauma … Assistant Professor of Pediatrics (Anaesthesia), Harvard Medical School Chair, Pediatric Acute Lung Injury … Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases.

674. 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.

675. 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.

676. Periodic Issue | PSNet
     psnet.ahrq.gov/periodic-issue/periodic-issue-303
     August 25, 2021 - Implementation of the worker safety reporting system reduced time from injury to reporting, identified … rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure

677. High-Risk Medications, High-Risk Transfers | PSNet
     psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
     December 21, 2017 - airway displacement), hemodynamic disturbances (including cardiac arrest), nosocomial infections, and injury … More Related Resources WebM&M Cases Under Pressure

678. 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 .

679. 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?

680. 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.