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  1. A Potent Medication Administered in a Not So Viable Route | PSNet

    psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
    July 20, 2016 - Use of vasopressors to raise blood pressure and improve perfusion in fluid refractory shock is considered … standard of care ( 1 ), with vasopressors generally titrated to achieve a mean arterial pressure of … Vasopressor medications achieve their desired effects on blood pressure through powerful vasoconstriction … of 49 hours (± 22 hours).( 4 ) While 2% of patients experienced vasopressor extravasation, no tissue injuries … Management of extravasation injuries: a focused evaluation of noncytotoxic medications.

  2. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
    January 01, 2024 - were worse when supine, but nocturnal headaches can be the presenting sign of elevated intracranial pressure … keep patients awake at night should prompt repeat imaging given the concern for elevated intracranial pressure … which allows time for the brain to adapt to tissue displacement and modestly increased intracranial pressure … Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma. … Trauma Surg Acute Care Open. 2018;3(1):e000129.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73363/psn-pdf
    June 09, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … shift nursing handover interventions associated with improved inpatient outcomes—falls, pressure injuries … identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure … injuries, medication administration errors).

  4. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-handouts.html
    June 01, 2017 - disorders/neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound … and Skin |___| Cellulitis |___| Edema |___| Infected wound or decubitus |___| Jaundice … |___| Rash Fall-Related Injury |___| Major injury |___| Minor injury Non-Fall-Related … Injury |___| Major injury |___| Minor injury Musculoskeletal |___| Joint pain/joint … status change |___| Mental disorder/psychosis |___| Neoplasm |___| Pneumonia |___| Pressure

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40507/psn-pdf
    June 08, 2011 - From research to practice: factors affecting implementation of prospective targeted injury-detection … From research to practice: factors affecting implementation of prospective targeted injury-detection … https://psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury … five hospitals faced in implementing new systems for prospective detection of adverse drug events and pressure … https://psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection

  6. Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    April 01, 2025 - the population at risk numbered at least 100, the highest rates for both 2021 and 2022 were worsening pressure … injuries that were present on admission (2021: 4.9%, 2022: 6.0%), hypoglycemic events (4.7% for both … Pressure Injury. Surgery/Anesthesia. Venous Thromboembolism. Other. … determined that national efforts to reduce hospital-acquired conditions such as adverse drug events and injuries

  7. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
    December 01, 2017 - measures that include falls, residents who fall, residents with two or more falls and fall related serious injuries … Changes in staff organization Reduction of survey tags and lawsuits related to falls and injuries … Include alarms attached to a wheelchair and consider all types of pressure or position change alarms … Item 14 asks if the resident's blood pressure was taken after the fall. … across from the injury site and specify the type of injury.

  8. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
    October 01, 2011 - year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease was admitted to a trauma … service after injuries suffered from an assault and battery. … The patient’s injuries included a left shoulder dislocation and a minimally displaced fracture of a thoracic … In reviewing the medical records, the PT noted the initial shoulder injury on admission. … ICU (4) In addition to providing a general assessment, the PT expressed concern that the shoulder injury

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867022/psn-pdf
    October 30, 2024 - were worse when supine, but nocturnal headaches can be the presenting sign of elevated intracranial pressure … keep patients awake at night should prompt repeat imaging given the concern for elevated intracranial pressure … which allows time for the brain to adapt to tissue displacement and modestly increased intracranial pressure … Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. … Trauma Surg Acute Care Open. 2018;3(1):e000129.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861738/psn-pdf
    January 31, 2024 - In a study of 165 patients undergoing wound exploration after hand laceration, 32% of tendon injuries … Explore wounds for evidence of arterial bleeding, foreign body, tendon injury, and arthrotomy. … A blood pressure cuff applied proximal to the wound is another option. … If a tendon injury cannot be ruled out after wound exploration and functional testing, assume an occult … injury exists.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837890/psn-pdf
    August 24, 2022 - Accuracy of pressure ulcer events in US nursing home ratings. … Accuracy of pressure ulcer events in US nursing home ratings. … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings All nursing homes … This study compared seven years of self-reported pressure ulcer data with claims-based data for pressure … does-nursing-home-compare-reflect-patient-safety-nursing-homes https://psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare

  12. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
    January 01, 2022 - Injuries or Complications of Pressure Injuries Present on Admission (POA) (4.9%), and Hypoglycemic … Injuries or Complications of Pressure Injuries POA (13.4% vs. 4.7%) and Catheter- associated Urinary … Injuries or Complications of Pressure Injuries POA is significantly higher (8.4% vs. 4.4%) for the … injuries or complications of pressure injuries present on admission (POA) was significantly higher … injuries or complications of pressure injuries present on admission (13.4% vs. 4.7%) and catheter-associated

  13. AHRQ QI List of Indicators (pdf file)

    qualityindicators.ahrq.gov/Downloads/Modules/V2023/AHRQ_QI_Indicators_List.pdf
    October 01, 2023 - • PSI 02 - Death Rate in Low-Mortality Diagnosis Related Groups (DRGs) • PSI 03- Pressure … Fracture Rate • PSI 09- Postoperative Hemorrhage or Hematoma Rate • PSI 10- Postoperative Acute Kidney Injury … or Deep Vein Thrombosis (PE/DVT) Rate • PSI 13- Postoperative Sepsis Rate • PSI 14 - Postoperative Wound … Rate - Injury to Neonate • PSI 18 - Obstetric Trauma Rate - Vaginal Delivery with Instrument • PSI … 19- Obstetric Trauma Rate - Vaginal Delivery without Instrument • PSI 90- Patient Safety and Adverse

  14. Conducting a Comprehensive Skin Assessment (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar4_pu_skinassesst_final.pdf
    April 01, 2011 - deep tissue injury – Preulceration in the diabetic foot – Inflammation or infection 15 Parameter … – Skin tears (especially forearm of older adults) – Trauma • Make sure to get the etiology right … For each patient, record— • Whether he/she has pressure ulcers • How many pressure ulcers he/she has … • Highest stage of his/her deepest ulcer • Treatment for any existing wounds 32 Reporting Results … Wound care essentials: practice principles. 3rd ed.

  15. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head | PSNet

    psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
    March 27, 2024 - were worse when supine, but nocturnal headaches can be the presenting sign of elevated intracranial pressure … keep patients awake at night should prompt repeat imaging given the concern for elevated intracranial pressure … which allows time for the brain to adapt to tissue displacement and modestly increased intracranial pressure … Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. … Trauma Surg Acute Care Open . 2018;3(1):e000129. [ Free full text ] Borst J, Godat LN, Berndtson AE,

  16. Staff Roles and Training forYour Pressure Ulcer Prevention Program (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar3_pu_staffroles.pdf
    January 01, 2014 - Program. 8 Wound Care Team: Roles and Duties • Serve as your hospital’s content experts on pressure … ulcer injury prevention … Nursing 2014 survey results: Wound care and prevention. … Advances in Skin and Wound Care. 2010; 23(3):120-31. • Levine J, et al. … Advances in Skin and Wound Care. 2007; 20(1):34-38. 37 Staff Roles and Training forYour Pressure

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867427/psn-pdf
    December 18, 2024 - Centers for Disease Control and Prevention (CDC) consistently reports falls as the leading cause of injury … The World Health Organization reports falls as the second leading cause of unintentional injury deaths … A patient fall is defined as “an unplanned descent to the floor with or without injury to the patient … In hospitals, falls with injuries can lead to other adverse outcomes including pressure injuries or … One study found that providing patients at risk for falls with Smart Socks, which contain pressure sensors

  18. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
    January 01, 2024 - wound.  … Trauma-induced coagulopathy: what you need to know. J Trauma Acute Care Surg. 2024;96(2):179-185. … Vascular injury and complication in neurosurgical spine surgery.  … Craniomaxillofac Trauma Reconstr. 2013;6(4):257-266. … Hetastarch during initial resuscitation from trauma. J Trauma. 2011;70(5 Suppl):S19-S21.

  19. In Conversation with David W. Bates about Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
    February 26, 2025 - Other important factors are nursing-sensitive events, which include things like pressure injuries and … For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … will develop a dangerous pressure injury. … Some of these sensors are expensive, but pressure injuries are extremely expensive. … will take a look at your pressure injuries practices and take steps to improve those.

  20. Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/are-we-safer-today
    February 26, 2025 - Other important factors are nursing-sensitive events, which include things like pressure injuries and … For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … will develop a dangerous pressure injury. … Some of these sensors are expensive, but pressure injuries are extremely expensive. … will take a look at your pressure injuries practices and take steps to improve those.
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