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1021. Lessons in Safety Climate and Safety Practices from a California Hospital Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Singer.pdf
      April 01, 2003 - This heightened interest has increased pressure on hospitals to reduce medical errors. … Increased regulatory and payer pressures have encouraged hospital leaders to undertake efforts to improve … For example, one consortium participant from a large multihospital network created an injury graph that … Based on this analysis, she categorized injuries by hospital. … The visual image helped motivate the organization to set system goals for reducing patient injuries.

1022. TeamSTEPPS Core Curriculum. | PSNet
      psnet.ahrq.gov/issue/teamstepps-core-curriculum
      August 01, 2012 - July 12, 2018 Pressure Injury Prevention in Hospitals Training Program.

1023. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840141/psn-pdf
      November 16, 2022 - reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure … injuries and healthcare-acquired infections.

1024. E-cigarette Explosion in a Patient Room | PSNet
      psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
      March 15, 2023 - 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 ( … 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.

1025. 'The ABC of Handover': impact on shift handover in the emergency department. | PSNet
      psnet.ahrq.gov/issue/abc-handover-impact-shift-handover-emergency-department
      June 17, 2010 - June 17, 2010 Teams under pressure in the emergency department: an interview study. … Settings Help Improve Management of Sepsis May 31, 2023 High delayed and missed injury … rate after inter-hospital transfer of severely injured trauma patients.

1026. Renal-Artery-Stenosis Surveillance (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/renal-artery-stenosis_surveillance.pdf
      June 01, 2012 - angioplasty with stent placement on long-term clinical outcomes (at least 6 months), including blood pressure … ; however, a smaller decrease in diastolic blood pressure in the revascularization group was observed … medical therapy “There was no significant between- group difference in systolic blood pressure; the … PTA+ stenting Blood Pressure Control: Cured, n (%): 0 vs. 4 (11.1%); p<0.001 Improved, n (%): 33 … hematoma or hemorrhage requiring hospitalization, 5 cases of clinically significant acute kidney injury

1027. Module 3. Falls Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mgdod3.html
      October 01, 2014 - In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Develop participants' knowledge and skills in preventing falls and fall-related injuries. … He has moderate dementia, and his blood pressure falls when he stands up too fast, making him dizzy. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury

1028. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33712/psn-pdf
      June 01, 2011 - analysts who see this behavior as a universal law: automobile seat belts actually do reduce deaths and injuries … So I think the combination of a high frequency of alarms and pressure for productivity is potentially … In studying some of the recent mine accidents, I found there was an institutional pressure there to … come not because people are greedy or selfish or that they don't care, but that their bias and the pressures

1029. Evidence Summary: Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Cardiovascular Disease Risk Factors: Behavioral Counseling Interventions | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary/healthy-lifestyle-and-physical-activity-for-cvd-prevention-adults-without-known-risk-factors-behavioral-counseling
      July 26, 2022 - For the purposes of this review, cardiovascular risk factors included elevated blood pressure, elevated … (high blood pressure stage 1 [systolic blood pressure [SBP] 130 mm Hg or diastolic blood pressure [DBP … behavioral outcome (eg, dietary intake, physical activity) or report adverse events (eg, serious harm, injury … different between groups. 29-31 , 48 , 56 , 82 Twelve trials reported the incidence of musculoskeletal injuries … including physical activity counseling reported generally no differences in rates of musculoskeletal injuries

1030. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
      January 01, 2023 - complications and the time period for ascertainment.11,14,17,18 – The most common complications are wound … Liver injury during PEG tube placement: report of two cases. … Trauma Surg Acute Care Open. 2022;7(1):e000800. [Free full text] 45. … Trauma transitional care coordination: a mature system at work. … J Trauma Acute Care Surg. 2018;84(5):711-717. [Available at 48.

1031. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
      March 01, 2015 - surgery is a sentinel event—an unexpected occurrence involving death or serious physical or psychological injuries … Incorrect or lack of consent Failure to use site markings Surgeon fatigue Multiple surgeons Unusual time pressures

1032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49737/psn-pdf
      June 01, 2015 - The misplaced catheter caused trauma to the urethra and blood loss. … With regulatory and financial pressures directed toward reducing hospital-acquired infections, attention … occurs more frequently in men who perform intermittent catheterizations frequently (e.g., spinal cord injury … J Wound Ostomy Continence Nurs. 2007;24:655-661. [go to PubMed] 2. … Assist in healing of open sacral/perineal wound in incontinent patients.

1033. Wheelchair-Service Research-Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/wheelchair-service_research-protocol.pdf
      July 01, 2010 - Adverse events/harms/safety issues (i.e., pressure sores, injuries, need for repairs, need for replacement … , functional and physiologic outcomes, patient satisfaction, use), and harms (i.e., development of pressure … common; includes power seating system a. tilt frame – tilts user backward in seated position to change pressure … points and help prevent pressure ulcers; also to improve seating balance b. reclining – reclining … backrest opens hip angle; for pressure relief, resting, or self- catheterization c. elevating – lifts

1034. The Forgotten Drip | PSNet
      psnet.ahrq.gov/web-mm/forgotten-drip
      April 01, 2014 - Multiple therapies were initiated to reduce the intracranial pressure and swelling, including intubation … The "Lund protocol," derived in patients with elevated ICP in the setting of head trauma, assumes that … Continuous recording and control of ventricular fluid pressure in neurosurgical practice. … Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am. 1995;6:761-773. … Hyperventilation in head injury: a review. Chest. 2005;127:1812-1827. [go to PubMed] 5.

1035. Medical malpractice: why is it so hard for doctors to apologize? | PSNet
      psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize
      August 24, 2011 - August 24, 2011 Assessment of nursing home reporting of major injury falls for quality … February 5, 2020 Accuracy of pressure ulcer events in US nursing home ratings.

1036. NASHP Environmental Scan 3-1 to TR v2.xls (pdf file)
      hcup-us.ahrq.gov/reports/race/50StateScan04_26forweb.pdf
      December 01, 2010 - and Illnesses, Census of Fetal Occupational Injuries, Current Population Survey), DPH Infectious … (2008) http://tinyurl.com/ 46tflsy Physical Activity, Mental Health, Tobacco Use, High Blood Pressure … Cancer, Cardiovascular Disease, Diabetes, Obesity, HIV/AIDS, Infant Mortality, Unintentional Injuries … Deaths, Deaths of Children 1-17, Deaths of teens 15-17, Tobacco Use, General Nutrition, Blood Pressure … Diabetes, Stroke, Homicide, Motor Vehicle Deaths, Suicide Deaths, Obesity, Tobacco Use, Blood Pressure

1037. Final Research Plan: Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd
      September 13, 2018 - activity for cardiovascular disease (CVD) prevention among adults with hypertension, elevated blood pressure … e.g., morbidity and mortality) in adults with known CVD risk factors (hypertension or elevated blood pressure … glucose, or body mass index) in adults with known CVD risk factors (hypertension or elevated blood pressure … What is the relationship between intermediate outcomes (e.g., blood pressure, lipid levels, blood glucose … Adverse outcomes Harms requiring medical attention (e.g., nutritional deficiency, musculoskeletal injury

1038. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
      May 01, 2015 - Her vital signs were notable for a temperature of 38.6° C, heart rate of 115 beats per minute, blood pressure … 2 hours despite adequate fluid resuscitation Creatinine > 2 mg/dL Worsening hypoxemia Acute lung injury … with PaO2/FiO2 < 250 in the absence of pneumonia as infection source Acute lung injury with PaO2/FiO2 … Shock Septic shock is defined as severe sepsis with lactate ≥ 4 mmol/L or hypotension (mean arterial pressure … [MAP] < 65 mm Hg; systolic blood pressure < 90 mm Hg) not responsive to a fluid bolus In this case,

1039. Developing a tool for assessing competency in root cause analysis. | PSNet
      psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
      May 01, 2014 - May 22, 2019 Fake it 'til you make it: pressures to measure up in surgical training. … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

1040. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49732/psn-pdf
      May 01, 2015 - 4 mmol/L or hypotension (mean arterial pressure [MAP] 4) In this case, the patient presented to the … mental status Lactate > 2 mmol/L Urinary output Creatinine > 2 mg/dL Worsening hypoxemia Acute lung injury … with PaO2/FiO2 Acute lung injury with PaO2/FiO2 Bilirubin > 2 mg/dL Platelet count 9/L International … normalized ratio > 1.5 Partial thromboplastin time > 60 seconds MAP: mean arterial pressure SBP: … systolic blood pressure Reprinted from (4) with permission from Wolters Kluwer Health, Inc.