-
effectivehealthcare.ahrq.gov/sites/default/files/Evidence%20Summary_2.pdf
May 01, 2020 - amniotomy, supportive care measures,
epidural analgesia, frequency of cervical
examination, intrauterine pressure … since cesarean delivery
itself increases the risk of maternal hemorrhage,
venous thromboembolism, and injury … Table W summarizes the SOE for intrauterine
pressure catheters versus external monitoring. … Intrauterine pressure catheters versus external monitoring: Evidence summary
in women of unspecified … Low (one study)
Neonatal Outcomes
– Neonatal Death,
major birth injury,
respiratory distress
transient
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - His initial vital signs in the ED were notable for a systolic blood pressure in the 100s and a heart … This suggests that the clinicians initially considered trauma but prematurely narrowed their focus to … additional history-taking may have revealed the patient’s recent history of falls with repeated closed head injuries … “Has this patient suffered recent head trauma or is this patient at increased risk of head trauma?”) … June 14, 2023
WebM&M Cases
Under Pressure: Delayed
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hcup-us.ahrq.gov/db/nation/nis/APS-DRGs%20V22%20Definitions%20Manual.pdf
April 01, 2006 - Ventilation - < 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 AGE >17
448 … ,POISON&TOXIC EFFECT DX
455 454 OTH INJURY,POISON&TOXIC EFFECT DX
461 461 O.R.
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digital.ahrq.gov/sites/default/files/docs/lesson/08-0063-ef-ambulatory-cpoe.pdf
May 01, 2008 - body of literature shows
that many patients experience adverse drug events (ADEs) or unanticipated injuries … in
nursing homes
5
The Institute of Medicine
estimates 98,000 deaths per year and many more injuries … For one of the grantees, significant
changes were noted in patients’ blood pressure and low-density … There was then pressure to implement the templates in all the
clinics, rather than the half randomized
-
psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
December 01, 2012 - , and worse long-term brain function [ 5 ]), it is worth thinking about delirium as an "acute brain injury … " similar to other end-organ injuries (e.g., heart attack, acute kidney injury). … As with these other important end-organ injuries, delirium is a clinical event for which prevention and … spontaneous breathing trials (SBT, defined as turning the ventilator settings to continuous positive airway pressure … My criteria for neuroimaging are that if someone has a history of head trauma or evidence of bruising
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/hro-rapid-research.pdf
May 01, 2025 - SSEs:
Truman reported 7 SSEs during the
study period: 5 at-home
unobserved falls with injury, 1
death … o Preventing Pressure Ulcers in Hospitals28: assist hospital staff in
implementing effective pressure … A "high-reliability organization" approach to
improve trauma imaging performance. … Preventing pressure ulcers in hospitals. … A "high-reliability organization" approach to
improve trauma imaging performance.
-
psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - lines, you don't have to go anywhere near the great vessels of the neck or the chest, so you avoid injury … You avoid injury to the lung—that dreaded complication of pneumothorax. … You just put pressure at that site in the arm and compress the vessel against the underlying humerus. … Think about it: when you insert a PICC, your needle causes endothelial injury, in a patient that's hypercoaguable
-
psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - diuresis, diarrhea, and fluid restriction, they ordered blood
products and albumin to increase oncotic pressure … responsive to fluid resuscitation,” with
the added requirement for vasopressors to maintain a mean arterial pressure … perforations.21
• Other identified risk factors include older age, presence of comorbidities,22 acute
kidney injury
-
psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A 2014 study of
women who gave birth found that 14.8% of respondents perceived pressure from a clinician … riskier.13 Babies delivered via
cesarean section are at risk for respiratory problems and surgical injury … www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655#:~:text=A%20C%2Dsection%20might%20increase,Wound … www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655#:~:text=A%20C%2Dsection%20might%20increase,Wound … Patient-perceived pressure from clinicians for labor
induction and cesarean delivery: a population-based
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - coronary care unit (CCU) with respiratory failure requiring mechanical ventilation and acute kidney injury … More
Related Resources
WebM&M Cases
Under Pressure
-
psnet.ahrq.gov/node/49593/psn-pdf
October 01, 2009 - how a safety pin could be aspirated, or a non-deformable endotracheal tube connector might cause a
pressure … injury to the nares if left in place for more than a brief period.
-
psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. … continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury
-
psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. … continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury
-
psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Umpires make crucial split-second decisions under conditions of substantial pressure
and uncertainty … Rarely, the error may
cause injury or death.
-
psnet.ahrq.gov/node/49419/psn-pdf
October 01, 2003 - is increased when multiple procedures are performed on the same patient, when a team is under time
pressure … Error disclosure for
patients, however, is merely the first step in a long process of adjustment to an injury
-
psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve … Latex is essential to these plants to heal surface injuries and create immune responses against invading … Thus, unexplained hypotension, tachycardia, and high airway pressure for adequate ventilation (due to … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury
-
psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - The bleeding was not stopped by local pressure, and he returned to the hospital, where he was found to … July 10, 2019
Classifying errors in preventable and potentially preventable trauma deaths … WebM&M Cases
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury
-
www.ahrq.gov/ncepcr/research-transform-primary-care/transform/tpcbib/index.html
May 01, 2015 - Hemoglobin A1c and blood pressure values in patients with diabetes were not significantly different between … The number of hospitalizations for unintentional injury and asthma also decreased after implementation … PMID: 23690385
The authors compared emergency care usage for any reason, asthma, and unintentional injury … As a comparison, emergency care use for unintentional injury had been increasing before and during implementation … Among patients with hypertension, frequent in-person visits were associated with better blood pressure
-
www.ahrq.gov/sites/default/files/publications/files/ena-slides.pdf
September 01, 2015 - Need for resources
• What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter
may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and
may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery
Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds
Consult with the wound care
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/guides/ena-slides.pdf
September 01, 2015 - Need for resources
• What teams need to be activated (specialists, code team, trauma team, brain injury … While a catheter
may prove useful in advanced-stage pressure ulcers, there are many other products that … Additionally, the presence of a catheter can cause pressure and
may damage fragile tissue. … • The patient who requires immobilization for trauma or surgery
Inquire about the length of the … • The patient who is incontinent with open sacral or perineal wounds
Consult with the wound care