-
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.
-
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
-
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
-
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
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-transcript.html
December 01, 2017 - 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.
-
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
-
www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … The toolkit draws on literature on best practices in pressure ulcer prevention and includes both validated … patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury
-
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
-
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
-
psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - this area from personal acquaintance with physicians and understanding their narratives of how legal pressures … it would be useful for us to deliberate about what we think the value of different common types of injuries … That caring relationship doesn't end when an injury occurs, particularly if the injury is our fault. … They reduce the underlying safety problems that can lead to injuries that lead to claims. … Then, we have a few cases in which EHR systems themselves have had problems that have led to injuries
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-prevent.html
March 01, 2017 - Infections cause pain, injury, disability, and sometimes even death, and can be very expensive to treat … signs, such as—
Increased temperature
Changes in respiration or pulse rate
Changes in blood pressure … resident, if needed, that the law requires the use of safety lancets and needles to prevent needle stick injuries … Make sure that wounds are covered.
Contain any urine, stool, or wound drainage. … An LTC facility must have negative pressure rooms and a respiratory fit-test program in order to safely
-
pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
January 01, 2020 - Late, Planned,
Unplanned
• Restraint Utilization
• Falls/Unassisted Falls
o By Diagnosis Group
• Injuries … Resulting from
Falls/Unassisted Falls
o By Diagnosis Group
• Pressure Injuries
• Venous Thromboembolism … Sharing
2019
• Our Recent TJC Survey Experience
• Eliminating CAUTI among patients with spinal cord injuries
-
psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - While the team adjusted the table, it swung loose and the patient fell to the floor but sustained no injury … 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 have … come not because people are greedy or selfish or that they don't care, but that their bias and the pressures
-
www.ahrq.gov/sites/default/files/2024-05/bruzzese3-report.pdf
January 01, 2024 - Soldiers with traumatic brain injuries. Athletes
with concussions. … care
o From pee wee to pro: Head injuries in sports
o Can the FDA ensure food safety? … Journalism Graduate Program
• How nanotechnology may revolutionize the detection of traumatic brain injury … interim deputy director, Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury … "Sim
Man" and "Harvey" reproduced physiological signs, such as blood pressure and heart and breathing
-
psnet.ahrq.gov/node/33578/psn-pdf
September 15, 2024 - anesthesia were integral to the redesign of anesthesia equipment, significantly reducing the risk of injury … critical system property, reflecting the organization's capacity to bounce back in the face of
continuing pressures
-
psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
February 26, 2025 - reason for us to make sure, at least from Leapfrog's spot, that there's a continued laser focus and pressure … We graded every hospital for which there's adequate data on errors, accidents, and injuries. … Then hopefully they will go to the hospital and put some pressure on them to elevate the priority of … How do I protect them from the errors and injuries that are rampant? What can I do better?
-
psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - history of hypertension, psychiatric illness, and a previous suicide attempt
overdosed on her blood pressure … The ED team thought this was likely due to severe
hypotension (her systolic blood pressure was around … The
possibilities for harm are numerous and include accidental trauma to non-venous structures (arteries … , lung,
nerve, visceral organs); bleeding (hematoma, hemothorax, or hemorrhage); operator injury (needle … wire, bloodstream infections, sheared catheter,
dysrhythmias, thrombosis, through-and-through vessel trauma
-
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,
-
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.
-
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.