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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.
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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
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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,
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psnet.ahrq.gov/node/73363/psn-pdf
June 09, 2021 - Shift-to-shift nursing handover interventions associated
with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an
integrative review. … shift nursing handover interventions associated with improved inpatient
outcomes—falls, pressure injuries … identify which nursing handover interventions result in improved
patient outcomes (i.e., patient falls, pressure … injuries, medication administration errors).
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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?
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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?
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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.
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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.
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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.
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psnet.ahrq.gov/node/44388/psn-pdf
October 14, 2015 - The study
looked at four nursing-sensitive adverse outcomes: pressure ulcers, falls with injuries, catheter-associated … hospitals had significantly fewer
of these hospital-acquired conditions, except for patient falls with injury … medicares-policy-not-pay-treating-hospital-acquired-conditions-impact
https://psnet.ahrq.gov/issue/preventing-falls-injury
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - wound. … Trauma-induced coagulopathy: what you need to know. … Vascular injury and complication in neurosurgical spine surgery. … Hetastarch during initial resuscitation from trauma. … J Trauma . 2011;70(5 Suppl):S19-S21. [ Available at ] Hahn RG.
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - , 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
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Ironically for this case, the greatest risk of bleeding from ALIF is usually from injury to
a major … the 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. … Hetastarch during initial resuscitation from trauma. J Trauma.
2011;70(5 Suppl):S19-S21.
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … manage potential foreign bodies, clinicians should have a low threshold for involving an experienced trauma … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery, Division of Trauma … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.
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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.
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psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - Commonly used agents that cause severe extravasation injuries include antineoplastic, inotropic, or osmotically … Use to Promote Wound Healing In contrast, the wound healing literature generally supports the use … Treating chronic and acute wounds with warming: review of the science and practice implications. … Local heat increases blood flow and oxygen tension in wounds. Arch Surg. 1987;122:221-225. … March 5, 2025
WebM&M Cases
Under Pressure: Tracheostomy
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - healing.2
17
17
General Approach to Wounds (4)
Eliciting the mechanism of injury will identify factors … the possibility of injury to deeper structures causing neurovascular injuries, fractures, or, for the … , arterial injury, open fracture, and foreign material.4,5
19
19
General Approach to Wounds (6) … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury … Wounds should be irrigated with moderate pressure (5-8 psi)
irrigant to reduce bacterial counts and … manage potential foreign bodies, clinicians should have a low threshold for involving an experienced
trauma … Consulting Editor, AHRQ’s Patient Safety Network (PSNet)
Professor
Department of Surgery, Division of Trauma … Primary closure versus delayed closure for non bite traumatic
wounds within 24 hours post injury.
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psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save-lot
September 13, 2017 - Falls and falls with injury are significant sources of morbidity and mortality and can have substantial … This study showed that after implementing the Fall TIPS program, falls and falls with injury decreased … November 3, 2021
Trauma resuscitation errors and computer-assisted decision support. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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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