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  1. 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.
  2. 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.
  3. 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
  4. 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
  5. 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?
  6. Psn-Pdf (pdf file)

    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?
  7. 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.
  8. Psn-Pdf (pdf file)

    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.
  9. 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
  10. 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
  11. 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
  12. 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
  13. Psn-Pdf (pdf file)

    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 pressureinjuries, falls, hospital- acquired urinary tract infections, and medication administration errors.
  14. 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
  15. 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.
  16. 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.
  17. 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
  18. 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 pressureinjuries.
  19. 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?
  20. 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,