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81. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/837890/psn-pdf
    August 24, 2022 - Accuracy of pressure ulcer events in US nursing home ratings. … Accuracy of pressure ulcer events in US nursing home ratings. … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings All nursing homes … This study compared seven years of self-reported pressure ulcer data with claims-based data for pressure … does-nursing-home-compare-reflect-patient-safety-nursing-homes https://psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare

82. A Potent Medication Administered in a Not So Viable Route | PSNet
    psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
    July 20, 2016 - Use of vasopressors to raise blood pressure and improve perfusion in fluid refractory shock is considered … standard of care ( 1 ), with vasopressors generally titrated to achieve a mean arterial pressure of … Vasopressor medications achieve their desired effects on blood pressure through powerful vasoconstriction … of 49 hours (± 22 hours).( 4 ) While 2% of patients experienced vasopressor extravasation, no tissue injuries … Management of extravasation injuries: a focused evaluation of noncytotoxic medications.

83. Preventing pressure ulcers: the goal is zero. | PSNet
    psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero
    September 30, 2010 - Commentary Preventing pressure ulcers: the goal is zero. … Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007;33(10):605-10. … Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007;33(10):605-10. … October 2, 2024 A randomized trial of a multifactorial strategy to prevent serious fall injuries … August 27, 2013 Preventing in-facility pressure ulcers as a patient safety strategy:

84. Periodic Issue | PSNet
    psnet.ahrq.gov/periodic-issue/periodic-issue-445
    May 29, 2024 - , major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. … The most common type of injury in both ASC and HOR was dental injury followed by nerve damage. … , major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. … The most common type of injury in both ASC and HOR was dental injury followed by nerve damage. … Postoperative PE/DVT, postoperative sepsis, and composite PSI-90 all decreased, while pressure ulcer

85. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head | PSNet
    psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
    March 27, 2024 - were worse when supine, but nocturnal headaches can be the presenting sign of elevated intracranial pressure … keep patients awake at night should prompt repeat imaging given the concern for elevated intracranial pressure … which allows time for the brain to adapt to tissue displacement and modestly increased intracranial pressure … Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. … Trauma Surg Acute Care Open . 2018;3(1):e000129. [ Free full text ] Borst J, Godat LN, Berndtson AE,

86. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/861738/psn-pdf
    January 31, 2024 - In a study of 165 patients undergoing wound exploration after hand laceration, 32% of tendon injuries … Explore wounds for evidence of arterial bleeding, foreign body, tendon injury, and arthrotomy. … A blood pressure cuff applied proximal to the wound is another option. … If a tendon injury cannot be ruled out after wound exploration and functional testing, assume an occult … injury exists.

87. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867022/psn-pdf
    October 30, 2024 - were worse when supine, but nocturnal headaches can be the presenting sign of elevated intracranial pressure … keep patients awake at night should prompt repeat imaging given the concern for elevated intracranial pressure … which allows time for the brain to adapt to tissue displacement and modestly increased intracranial pressure … Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. … Trauma Surg Acute Care Open. 2018;3(1):e000129.

88. Are We Safer Today? | PSNet
    psnet.ahrq.gov/perspective/are-we-safer-today
    February 26, 2025 - Other important factors are nursing-sensitive events, which include things like pressure injuries and … For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … will develop a dangerous pressure injury. … Some of these sensors are expensive, but pressure injuries are extremely expensive. … will take a look at your pressure injuries practices and take steps to improve those.

89. In Conversation with David W. Bates about Are We Safer Today? | PSNet
    psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
    February 26, 2025 - Other important factors are nursing-sensitive events, which include things like pressure injuries and … For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … will develop a dangerous pressure injury. … Some of these sensors are expensive, but pressure injuries are extremely expensive. … will take a look at your pressure injuries practices and take steps to improve those.

90. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867427/psn-pdf
    December 18, 2024 - Centers for Disease Control and Prevention (CDC) consistently reports falls as the leading cause of injury … The World Health Organization reports falls as the second leading cause of unintentional injury deaths … A patient fall is defined as “an unplanned descent to the floor with or without injury to the patient … In hospitals, falls with injuries can lead to other adverse outcomes including pressure injuries or … One study found that providing patients at risk for falls with Smart Socks, which contain pressure sensors

91. A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals. | PSNet
    psnet.ahrq.gov/issue/comprehensive-program-reduce-rates-hospital-acquired-pressure-ulcers-system-community
    May 12, 2021 - Study A comprehensive program to reduce rates of hospital-acquired pressure ulcers … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … This implementation study sought to reduce incidence of pressure ulcers in hospitalized patients using … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … injury policy.

92. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49389/psn-pdf
    February 01, 2003 - The anesthesiologist then noted a rapid decrease in the patient’s blood pressure and increasing tachycardia … , indicating a possible vascular injury. … Pressure was applied and vascular surgery was consulted. … underreporting of vascular injury. … How can this type of injury be prevented?

93. Procedural Mishap: Learning Curve? | PSNet
    psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - The anesthesiologist then noted a rapid decrease in the patient’s blood pressure and increasing tachycardia … , indicating a possible vascular injury. … Pressure was applied and vascular surgery was consulted. … of underreporting of vascular injury. … How can this type of injury be prevented?

94. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47788/psn-pdf
    March 06, 2019 - Medical device-related pressure ulcers: a systematic review and meta-analysis. … Medical device-related pressure ulcers: A systematic review and meta-analysis. … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis … Hospital-acquired pressure ulcers are considered never events and represent a significant source of … This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related

95. Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals | PSNet
    psnet.ahrq.gov/issue/challenges-and-potential-solutions-patient-safety-infectious-agent-isolation-environment
    October 27, 2021 - The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related … October 13, 2018 Trauma Resuscitation Using in situ Simulation Team Training (TRUST) … July 21, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

96. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. | PSNet
    psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
    August 04, 2021 - From research to practice: factors affecting implementation of prospective targeted injury-detection … From research to practice: factors affecting implementation of prospective targeted injury-detection … five hospitals faced in implementing new systems for prospective detection of adverse drug events and pressure … From research to practice: factors affecting implementation of prospective targeted injury-detection

97. Spotlight
    psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
    January 01, 2024 - wound.  … Trauma-induced coagulopathy: what you need to know. J Trauma Acute Care Surg. 2024;96(2):179-185. … Vascular injury and complication in neurosurgical spine surgery.  … Craniomaxillofac Trauma Reconstr. 2013;6(4):257-266. … Hetastarch during initial resuscitation from trauma. J Trauma. 2011;70(5 Suppl):S19-S21.

98. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33561/psn-pdf
    September 07, 2019 - , while being cared for in a healthcare setting Care management events Patient death or serious injury … associated with unsafe administration of  blood products Maternal death or serious injury associated … of a neonate associated with labor or delivery in a low-risk pregnancy Patient death or serious injury … associated with a  fall while being cared for in a healthcare setting Any stage 3, stage 4, and unstageable pressure … Because Never Events are devastating and preventable, health care organizations are under increasing pressure

99. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49796/psn-pdf
    June 01, 2017 - did not recover spontaneous circulation for more than 30 minutes and sustained severe anoxic brain injury … For example, the trauma surgery service did not routinely perform a clamping trial before chest tube … most common complication), recurrent pneumothorax, infection (including empyema), organ or vessel injury … Complications following thoracic trauma managed with tube thoracostomy. Injury. 2012;43:46-50. … Complications of tube thoracostomy for acute trauma. Am J Surg. 1980;140:738-741.

100. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49524/psn-pdf
     November 01, 2006 - LMA use have been reported.(6) The most common complications include aspiration and unintended local trauma … with LMAs and high peak inspiratory pressures, allowing for inspired gases to insufflate the stomach … LMA use can also lead to injuries secondary to high cuff pressure and volume during prolonged procedures … These increased intra-cuff pressures can cause a significant damage to surrounding tissues. … the pyriform sinus, which is where the recurrent laryngeal nerve enters, rendering it vulnerable to injury