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1161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843051/psn-pdf
      February 01, 2023 - prevent the development of hematoma after ACSS.18 Additionally, maneuvers that transiently raise venous pressure … Patients undergoing ACSS are commonly admitted to the hospital postoperatively for wound observation, … Early identification is crucial, as airway obstruction may evolve rapidly and hypoxic brain injury follows … Clear steri-strips and pull suture Open wound – cut skin and platysma stitches Open wound – cut strap … Hypoxic brain injury occurs rapidly after airway obstruction, and prompt recognition and management

1162. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet
      psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
      September 25, 2019 - Due to the delayed diagnosis, the patient suffered permanent brain injury requiring around-the-clock … These barriers include professional hierarchy, time pressure, challenging workloads, and inadequate structures … Post-Tracheostomy Care May 29, 2024 WebM&M Cases Under Pressure … Infusion July 31, 2023 WebM&M Cases Under Pressure

1163. Environmental, Clinical and Economic Outcomes of Hospital Resources to Prevent Hospital-Acquired Infections (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/prevent-hai-protocol.pdf
      April 16, 2024 - for general bedside care, including but not limited to PPE, drapes, linens, laryngoscopes, blood pressure … ICU stay related to HAI; Length of stay; Mortality; Adverse effects; Healthcare worker infection or injury … OR laryng* OR trachea*) NEAR/3 (blade* OR scope* OR tube*)) OR laryngoscope*):ti,ab,kw #6 Blood pressure … cuffs 'blood pressure cuff'/de OR 'sphygmomanometer'/exp OR (cuff OR cuffs OR oximet* OR sphygmomanomet

1164. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet
      psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
      September 24, 2024 - safety culture and found a 37% increase in reporting, and decreases in preventable harm: 39% decrease in injuries … with falls, 37% fewer pressure injuries and a 34% reduction in central line-associated blood stream … For instance, a hospital may focus on eliminating severe pressure injuries as a preventable harm, but

1165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33614/psn-pdf
      June 01, 2005 - //#ref1 https://psnet.ahrq.gov//#ref2 https://psnet.ahrq.gov//#ref2 https://psnet.ahrq.gov//#ref3 injuries … intervention, they referred to any event that resulted in the emergency team being called—low blood pressure … the error caught by their regular physician, others would experience asymptomatic reduction in blood pressure

1166. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - transferred by ambulance to a tertiary Emergency Department (ED) from a referring hospital due to a left leg injury … holding her left hip flexed with significant tenderness on examination, but there were no other signs of trauma … safety during a diagnostic or therapeutic procedure.”4,5 Sedation can also ameliorate the psychological trauma … Patients often require assistance in maintaining a patent airway, and positive pressure ventilation … exist when sedation is urgently needed to prevent harm associated with the underlying condition or injury

1167. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet
      psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
      May 01, 2005 - Angina is typically described as a pressure-like or squeezing sensation in the chest, associated with … remember that electrocardiographic changes are not seen in unstable angina, as there is no permanent injury … limit Table adapted from Long et al. (2017) 9 1 Examples of risk factors include retrosternal pain, pressure

1168. Diagnostic Safety Centers of Excellence Grants Awarded in FY 2022 | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/research/grants-2022.html
      July 01, 2025 - Use of ChatGPT for Urinary Symptom Management Among People With Spinal Cord Injury or Disease: Qualitative … evidence, diagnostic practices, and outcomes for the problems of unintentional weight loss, high blood pressure … clinical problems above, based on analysis of EHR data; existing evidence, including from a home blood pressure

1169. Improving Patient Safety in Long-Term Care Facilities: Training Modules (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcinstructor.pdf
      June 01, 2012 - safety, create a more resident-centered environment, and reduce the number of falls and fall-related injuries … In addition, they should be able to manage injuries that result from falls. … Risk factors are identified, and ways to prevent injury are discussed. … Paul comes to visit his father after work; he is aware that his father fell yesterday, without injury … use to reduce the number of falls. › Nursing staff must have the knowledge and skills to prevent injury

1170. Making Healthcare Safer IV Rapid Response: Acute Care Nursing Staff Shortages That Compromise Patient-to-Nurse Ratios (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/nursing-staff-shortages-rapid-research.pdf
      April 01, 2025 - injuries, catheter-associated urinary tract infections, surgical site infections, and sepsis cases … The emergency department was restructured to cohort patients by specialty (e.g., trauma, pediatrics … The emergency department was restructured to cohort patients by specialty (e.g., trauma, pediatrics) … pandemic, and which sought to re-organize work structures to enhance nurses’ ability to cope with these pressures … California's nurse-to-patient ratio law and occupational injury.

1171. Microsoft Word - covtoc.doc (pdf file)
      hcup-us.ahrq.gov/db/nation/nis/APS-DRGsV20DefinitionsManual.pdf
      January 13, 2015 - 96 Hours 9672 Continuous Mechanical Ventilation -- 96+ Hours 9390 Continuous Positive Airway Pressure … 440 440 WOUND DEBRIDEMENTS FOR INJURIES 441 441 HAND PROCEDURES FOR INJURIES 442 442 OTHER O.R … PROCEDURES FOR INJURIES 443 442 OTHER O.R PROCEDURES FOR INJURIES 444 444 TRAUMATIC INJURY AGE … >17 445 444 TRAUMATIC INJURY AGE >17 446 446 TRAUMATIC INJURY AGE 0-17 447 447 ALLERGIC REACTIONS … ,POISON&TOXIC EFFECT DX 455 454 OTH INJURY,POISON&TOXIC EFFECT DX 461 461 O.R.

1172. Microsoft Word - APS_DRG_Def_Public_V211.doc (pdf file)
      hcup-us.ahrq.gov/db/nation/nis/APS-DRGs%20V21%20Definitions%20Manual.pdf
      January 13, 2015 - < 96 Hours 9672 Continuous Mechanical Ventilation -- 96+ Hours 9390 Continuous Positive Airway Pressure … 440 440 WOUND DEBRIDEMENTS FOR INJURIES 441 441 HAND PROCEDURES FOR INJURIES 442 442 OTHER O.R … PROCEDURES FOR INJURIES 443 442 OTHER O.R PROCEDURES FOR INJURIES 444 444 TRAUMATIC INJURY AGE … >17 445 444 TRAUMATIC INJURY AGE >17 446 446 TRAUMATIC INJURY AGE 0-17 447 447 ALLERGIC REACTIONS … ,POISON&TOXIC EFFECT DX 455 454 OTH INJURY,POISON&TOXIC EFFECT DX 461 461 O.R.

1173. Wrong Turn through Colon: Misplaced PEG | PSNet
      psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
      May 01, 2017 - early (≤ 72 hours) or late (> 72 hours).( 10 ) Minor complications include tube clogging, superficial wound … insertion site, hemorrhage, peritonitis, buried bumper syndrome, gastrocolocutaneous fistula, small bowel injury … healing.( 3 ) All dressing changes should incorporate a careful wound inspection for redness or leakage … disease, central nervous system tumor, amyotrophic lateral sclerosis, cerebral palsy • Severe trauma … Invaginate gastric wall, visible from endoscope with external digital pressure 4.

1174. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care | PSNet
      psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
      November 25, 2020 - Her vital signs included: blood pressure 154/113 mmHg, heart rate 75 beats/minute, respiratory rate 16 … Despite high levels of ED crowding, there is mounting pressure to see more patients in less time and … Patients with dangerous medical conditions and traumatic injuries may present with normal or near-normal … Multidisciplinary Simulation-Based Team Training for Trauma Resuscitation: A Scoping Review. … June 14, 2023 WebM&M Cases Under Pressure: Delayed

1175. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet
      psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
      October 01, 2004 - Mostly in response to increasing pressure from the hospital's administration to improve compliance with … Intramuscular injection site injuries masquerading as pressure ulcers. Wounds. 2003;15:302-312.

1176. Identifying, Understanding, and Communicating Medical Device Use Errors: Observations from an FDA Pilot Program (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Flack.pdf
      January 01, 2005 - 519, mandates that all manufacturers of medical devices must report device-related deaths, serious injuries … facilities” must report medical device related deaths to FDA and to the manufacturer and report serious injuries … of medical devices so it could become more proactive in addressing device issues before a death or injury … the various types and sizes of facilities that are obligated to make reports of deaths and serious injuries … systems are really at the root of the problem, and c) clinicians report they are just too busy with the pressures

1177. Final Progress Report: Demonstration Project To Refine, Automate and Test a Novel Emergency Department Trigger Tool (pdf file)
      www.ahrq.gov/sites/default/files/2025-02/griffey-report.pdf
      January 01, 2025 - preventable.6-9 Numerous factors, such as increasing acuity, limited data for decision making, time pressures … We queried home medications, chief complaint, triage data such as acuity and trauma leveling, keywords … BiPAP – bilevel positive airway pressure; CPAP – continuous positive airway pressure; D50 – 50% Dextrose … (11%), and pressure ulcers (12.3%). … hypoxia and hypotension, delirium/ confusion, various bleeding events, surgical complications and injuries

1178. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60269/psn-pdf
      April 29, 2020 - Wound infections are routinely managed by operating surgeons of all types, but whether an NSTI fits … If he or she described a ‘wound infection in a plastic surgery patient,’ https://psnet.ahrq.gov//#6 … Burnout Physician burnout (also referred to as “moral injury”) is an ongoing topic of discussion in … survey of subspecialty surgeons: “while EGS surgeons appear to meet [a clinical] need and relieve some pressure … Journal of Trauma and Acute Care Surgery. 2018 July;85(1):208-214.

1179. Safe Practices for Better Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer1.pdf
      April 01, 2004 - Not surprisingly, health care errors and consequent adverse events are a leading cause of death and injury … Introduction Health care errors and consequent adverse events are a leading cause of death and injury … Evaluate each patient upon admission, and regularly thereafter, for his or her risk of developing pressure … contrast media-induced renal failure, and use a clinically appropriate method for reducing risk of renal injury … Use of specialized hospital flooring to reduce injury from patient falls. 3.

1180. Survey on Patient Safety (facility version) (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
      June 02, 2025 - • “Patient safety” is defined as the avoidance and prevention of patient injuries or adverse events … Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking