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psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize
August 24, 2011 - August 24, 2011
Assessment of nursing home reporting of major injury falls for quality … February 5, 2020
Accuracy of pressure ulcer events in US nursing home ratings.
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psnet.ahrq.gov/issue/abc-handover-impact-shift-handover-emergency-department
June 17, 2010 - June 17, 2010
Teams under pressure in the emergency department: an interview study. … Settings Help Improve Management of Sepsis
May 31, 2023
High delayed and missed injury … rate after inter-hospital transfer of severely injured trauma patients.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - Falls Management Program
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Provider Fax Report and Orders
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … professionals/onthejob/falls.asp
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/index.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx … /fallspx/fallspxmanapb10pcp.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries
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digital.ahrq.gov/sites/default/files/docs/citation/appendix-e-cdspain-sample-clinical-practice-guidelines.docx
October 16, 2020 - Pain persisting or recurring for more than 3 to 6 months and can be caused by a disease or condition, injury … an unknown reason.1,2
Acute Pain – Pain that usually starts suddenly and has a known cause, like an injury … tachycardia, myoclonus)
First line
· Clonidine 0.1-0.2 mg oral every 6-8 hours; hold dose if blood pressure … check 1 hour post dose; obtain daily blood pressure checks; increasing dose requirements additional … blood pressure checks
· Re-evaluate in 3-7 days; taper to stop; average duration 15 days
Alternatives
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psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
May 26, 2016 - Considered a never event for hospitalized patients, falls that result in serious injury remain relatively … October 5, 2015
Preventing in-facility pressure ulcers as a patient safety strategy: … March 13, 2013
Venous thromboembolism after trauma: a never event?
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … new-recommendations-duty-hours-acgme-task-force
decreased risk of motor vehicle crash involvement and needlestick injury … Simplify the treatment when tired or under time pressure
When clinicians are tired or pressured for … Work schedule, needle use, and needlestick injuries among
registered nurses. … Can workplace rest breaks prevent work-related injuries related to long
working hours?
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - respiratory monitoring for 24 hours after intrathecal morphine injection, and potential neurological injury … ; this change was associated with decreased risk of motor vehicle crash involvement and needlestick injury … Work schedule, needle use, and needlestick injuries among registered nurses. … Can workplace rest breaks prevent work-related injuries related to long working hours? … Effects of coffee on ambulatory blood pressure in older men and women: a randomized controlled trial.
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psnet.ahrq.gov/node/73998/psn-pdf
October 27, 2021 - Blood products and intravenous fluids were infused under pressure into the external jugular
intravenous … efflux of solutions from a vessel into the surrounding tissue during
an infusion” and may cause grave injury … If an internal jugular venous catheter is placed, the venous pressure should be
transduced, and the … Outcomes and management of peripheral intravenous infiltration
injuries. Hand (NY). … Vascular access, fluid resuscitation, and blood transfusion in
pediatric trauma.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19f.html
March 01, 2023 - 5,990
6,632
Composite: ACSC Overall
23,094
19,763
20,681
21,282
21,204
19,420
Pressure … 5,861
6,673
6,037
6,455
Composite: ACSC Overall
20,343
22,153
21,427
18,076
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19g.html
March 01, 2023 - 12,136
Composite: ACSC Overall
32,463
23,973
25,306
28,599
25,757
29,466
Pressure … 12,380
10,227
12,540
Composite: ACSC Overall
24,470
31,390
25,983
29,126
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19e.html
March 01, 2023 - 6,924
7,208
Composite: ACSC Overall
20,218
17,976
20,084
17,046
19,215
17,075
Pressure … 6,471
8,020
7,037
6,881
Composite: ACSC Overall
17,757
20,393
19,476
16,171
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19d.html
March 01, 2023 - 3,685
2,830
Composite: ACSC Overall
6,401
5,144
6,083
4,903
6,049
4,408
Pressure … 3,503
3,242
3,720
2,668
Composite: ACSC Overall
5,768
5,111
6,087
4,163
Pressure
-
psnet.ahrq.gov/node/73389/psn-pdf
June 16, 2021 - estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-
medical-and-surgical
Some adverse events are sensitive to aspects of nursing care, including pressure … injuries, falls, hospital-
acquired urinary tract infections, and medication administration errors.
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd
September 13, 2018 - activity for cardiovascular disease (CVD) prevention among adults with hypertension, elevated blood pressure … e.g., morbidity and mortality) in adults with known CVD risk factors (hypertension or elevated blood pressure … glucose, or body mass index) in adults with known CVD risk factors (hypertension or elevated blood pressure … What is the relationship between intermediate outcomes (e.g., blood pressure, lipid levels, blood glucose … Adverse outcomes
Harms requiring medical attention (e.g., nutritional deficiency, musculoskeletal injury
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - Multiple therapies were initiated to reduce the intracranial pressure and swelling, including intubation … The "Lund protocol," derived in patients with elevated ICP in the setting of head trauma, assumes that … Continuous recording and control of ventricular fluid pressure in neurosurgical practice. … Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am. 1995;6:761-773. … Hyperventilation in head injury: a review. Chest. 2005;127:1812-1827. [go to PubMed] 5.
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psnet.ahrq.gov/issue/ed-handoffs-observed-practices-and-communication-errors
October 19, 2022 - intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood pressure … July 21, 2021
High delayed and missed injury rate after inter-hospital transfer of severely … injured trauma patients.
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hcup-us.ahrq.gov/reports/race/50StateScan04_26forweb.pdf
December 01, 2010 - and Illnesses, Census of
Fetal Occupational Injuries,
Current Population Survey), DPH
Infectious … (2008)
http://tinyurl.com/
46tflsy
Physical Activity, Mental
Health, Tobacco Use, High
Blood Pressure … Cancer,
Cardiovascular Disease,
Diabetes, Obesity, HIV/AIDS,
Infant Mortality, Unintentional
Injuries … Deaths, Deaths
of Children 1-17, Deaths of
teens 15-17, Tobacco Use,
General Nutrition, Blood
Pressure … Diabetes, Stroke, Homicide,
Motor Vehicle Deaths, Suicide
Deaths, Obesity, Tobacco Use,
Blood Pressure
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psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
May 01, 2014 - May 22, 2019
Fake it 'til you make it: pressures to measure up in surgical training. … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.
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psnet.ahrq.gov/issue/are-measurements-patient-safety-culture-and-adverse-events-valid-and-reliable-results-cross
February 04, 2015 - Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … July 1, 2016
Does time pressure have a negative effect on diagnostic accuracy?
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - Her vital signs were notable for a temperature of 38.6° C, heart rate of 115 beats per minute, blood pressure … 2 hours despite adequate fluid resuscitation
Creatinine > 2 mg/dL
Worsening hypoxemia
Acute lung injury … with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
Acute lung injury with PaO2/FiO2 … Shock
Septic shock is defined as severe sepsis with lactate ≥ 4 mmol/L or hypotension (mean arterial pressure … [MAP] < 65 mm Hg; systolic blood pressure < 90 mm Hg) not responsive to a fluid bolus
In this case,