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  1. 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
  2. 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
  3. 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.
  4. 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
  5. 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
  6. 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.
  7. 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
  8. 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
  9. Psn-Pdf (pdf file)

    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
  10. 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
  11. Psn-Pdf (pdf file)

    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 pressureinjury to the nares if left in place for more than a brief period.
  12. 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
  13. 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
  14. Psn-Pdf (pdf file)

    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.
  15. Psn-Pdf (pdf file)

    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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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