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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
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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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.doc
September 10, 2013 - So because of his immobility, he developed a pressure ulcer on his sacrum and the physician decided to … Now we know the elderly are very vulnerable to infection and other injury in the hospital. … Possibly, the patient needs immobilization for trauma or surgery, patient is incontinent with open wounds … ; protocolized care for trauma; incontinence without open sacral or perineal wounds; pre-operative placement … On the next slide, we’ll – one case study is trauma.
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - 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 or … 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
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Laboratory
tests showed acute kidney injury with markedly elevated levels of potassium, phosphate, and … The
patient's blood pressure improved with fluids. … Six hours after admission, the patient's blood pressure started to drop, requiring further intravenous … Despite aggressive measures to maintain her circulation, blood
pressures further dropped, and a code
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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
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapa2.html
April 01, 2018 - Other risk factors were male sex (OR 2.01, 95% CL 0.44-10.45), injury-operation interval less than … The incidence increased from 13.2% in clean wounds to 70.0% in dirty wounds. … for specific operation
Intraoperative recommendations
Ventilation
Maintain positive-pressure … Risks include effusions (12% or procedures), deep vein thrombosis (1.8%-46%), nerve injuries, and arterial … injury or aneurysm formation.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-final-es.pdf
October 01, 2022 - injury deaths),
followed by accidental falls and motor vehicle accidents (each of which accounted for … approximately 20% of unintentional injuries) … an important cause of death that
disproportionately affects younger populations, was unintentional injury … • Among the top 10 causes of YPLL, rates of unintentional injury, heart disease, liver disease,
and … eclampsia/preeclampsia rate, which measures a complication of pregnancy
characterized by high blood pressure
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digital.ahrq.gov/sites/default/files/docs/citation/r01hs023837-gurses-final-report-2021.pdf
January 01, 2021 - teams, that work under high time
pressure and safety-critical situations. … injuries. … Scale score, injury severity score (ISS), and
ED LOS. … activation level,
mode of arrival (ground or air transport), injury severity score (ISS), injury type … are missed injuries.
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hcup-us.ahrq.gov/reports/ataglance/HCUPAnalysisCA2018Wildfires.pdf
November 07, 2019 - (Including Burns)
Figures 7a–7l present ED visits for the initial encounter of injuries (including … ICD-10-CM Code
Range Injury Code Range Description
S00- to S99 Injuries head, neck, thorax, abdomen … shoulder, arm, elbow, forearm, wrist, hand, hip, thigh, knee, leg, ankle, and foot
T07- to T14- Injuries … effects of health and light, hypothermia, other effects of reduced
temperature, effects of air and water pressure … unspecified effects of other external causes and adverse effects
T79- Certain early complications of trauma
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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
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - When continuous positive airway pressure is prescribed for sleep apnea for these patients, it may not … anesthetic with an endotracheal tube was therefore necessary in this case so that positive end expiratory pressure … so quickly. 24 Inserting an airway, applying high flow nasal oxygen or continuous positive airway pressure … April 24, 2024
WebM&M Cases
Uterine Artery Injury
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - 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 … s preference to avoid invasive ventilation, she was started on noninvasive bi-level positive airway pressure … with uncertain outcomes, such as successful cardiac resuscitation with resultant severe anoxic brain injury
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psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
February 23, 2022 - The patient’s blood pressure was 174/101 mmHg, heart rate 126, respiratory rate 26, temperature 37.5 … The patient’s laboratory results were notable for acute kidney injury and metabolic acidosis, with an … only reported in 38 cases, but operator error, distraction, interruption, and emergency or after-hours pressure … December 4, 2024
WebM&M Cases
Under Pressure: Tracheostomy
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/healthy-lifestyle-and-physical-activity-for-cvd-prevention-adults-without-known-risk-factors-behavioral-counseling
June 04, 2020 - Abbreviations: BP=blood pressure; BMI=body mass index; CVD=cardiovascular disease; yr=year. … activity, and reduce sedentary behavior improve intermediate outcomes associated with CVD (g., blood pressure … *CVD risk factors include hypertension or elevated blood pressure, dyslipidemia or elevated lipid levels … intervention (e.g., nutritional deficiencies, disordered eating, symptoms of anxiety, musculoskeletal injuries … † Persons with known traditional CVD risk factors (i.e., hypertension or elevated blood pressure,
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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,
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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.
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psnet.ahrq.gov/issue/are-measurements-patient-safety-culture-and-adverse-events-valid-and-reliable-results-cross
February 04, 2015 - Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … July 1, 2016
Does time pressure have a negative effect on diagnostic accuracy?
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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.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/renal-artery-stenosis_executive.pdf
October 01, 2006 - Renal artery revascularization
may provide immediate improvement in kidney
function and blood pressure … While there was a benefit in blood pressure
after angioplasty, particularly in patients with bilateral … patients, transient deterioration of kidney function in 1
to 13 percent, renal artery or parenchymal injury … are independently
associated with direct kidney injury. … Blood pressure Acceptable • The 2 RCTs both found some evidence of greater blood pressure
improvement