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Showing results for "pressure injury".
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  1. Ambulatory Computerized Provider Order Entry (CPOE) (pdf file)

    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

  2. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet

    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

  3. Making Healthcare Safer IV Rapid Review: Examining the Impact of Implementing High-Reliability Organization Principles on Patient Safety Outcomes (pdf file)

    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.

  4. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy | PSNet

    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

  5. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)

    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

  6. In Conversation With… Vineet Chopra, MD, MSc | PSNet

    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

  7. Disposition of Comments for Chronic Urinary Retention: Comparative Effectiveness and Harms of Treatments (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/chronic-urinary-retention_disposition-comments.pdf
    September 15, 2014 - acontractile detrusor secondary to cauda equine or peripheral nerve injury) It is more appropriate … In these cases, the primary goals of therapy are to reduce storage pressures (treat detrusor overactivity … The whole idea behind using botulinum toxin is to reduce storage pressures and reduce incontinence. … The Cruz study enrolled “patients with multiple sclerosis (MS; n = 154) or spinal cord injury (SCI; … to under active detrusor (failed contractility due to obstruction leading to CUR and measured by pressure

  8. Archived: Problem Drinking: Screening, 1996 | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/recommendation/problem-drinking-screening-1996
    January 01, 1996 - 100,000 deaths attributed to alcohol annually, nearly half are due to unintentional and intentional injuries … The leading causes of death in adolescents and young adults — motor vehicle and other unintentional injuries … 60%) in various studies, 54 , 55 , 72 but elevations in GGT may be due to other causes (medications, trauma … Two additional studies demonstrated significant reductions in blood pressure as a result of advice to … The combined effects of aerobic exercise and alcohol restriction on blood pressure and serum lipids:

  9. Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/resources/asc-resource_list.pdf
    March 01, 2016 - Staffing, Work Pressure, and Pace ................................ 4 Composite 4. … Effective Crisis Management Living a Culture of Patient Safety Policy and Brochure Medically Induced Trauma … Staffing, Work Pressure, and Pace 1. … portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury … Staffing, Work Pressure, and Pace Composite 4. Teamwork Composite 5. Staff Training Composite 6.

  10. 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

  11. Emergency Nurses Association content and transcript (pdf file)

    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

  12. Emergency Nurses Association content and transcript (pdf file)

    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

  13. Coming Undone: Failure of Closure Device | PSNet

    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

  14. 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

  15. 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.

  16. Lost in Sign Out and Documentation | PSNet

    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

  17. 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 pressure … injury to the nares if left in place for more than a brief period.

  18. Periodic Issue | PSNet

    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

  19. Periodic Issue | PSNet

    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

  20. AHRQ Transforming Primary Care Grants Bibliography | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/reports/grants-transform/bibliography/index.html
    February 01, 2017 - 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
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