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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - increased with a 40% rise in healthcare-acquired infections and an increase in inpatient falls and pressure … ulcers. 14 Healthcare leaders recognize the need to do better. … ulcers, and other complications. … Falls and pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing … major injury increase by 17% and pressure ulcers increase by over 40%.
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psnet.ahrq.gov/periodic-issue/periodic-issue-352
July 08, 2022 - adverse drug events, hospital-acquired infections, postoperative adverse events, hospital-acquired pressure … ulcers, falls) over time among patients hospitalized for four common conditions – acute myocardial infarction … adverse drug events, hospital-acquired infections, postoperative adverse events, hospital-acquired pressure … ulcers, falls) over time among patients hospitalized for four common conditions – acute myocardial infarction
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citati…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - systematically addresses most likely areas of risk (e.g., central line infection, urinary infection, delirium, pressure … ulcers), and (iv) using the daily goal sheet to promote ongoing open dialogue.
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - contribute to delirium, hypotension, falls, and immobility along with its complications, such as pressure … ulcers and, as may have occurred in this case, aspiration pneumonia.
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - We also experienced, as Rhonda mentioned, difficulties with pressure ulcer prevention and timely response
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - We also experienced, as Rhonda mentioned, difficulties with pressure ulcer prevention and timely response
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psnet.ahrq.gov/node/865296/psn-pdf
March 27, 2024 - facilitating clinician communication, as well as preventing hospital-associated infections, falls, pressure … ulcers, and inpatient suicide.
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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - individuals can gain from social interaction and enhanced mobility, such as reduced risk of falls and
pressure … ulcers. … mitigate safety risks associated with usual care
needs for this patient population, such as falls and pressure … ulcers.
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - SPOTLIGHT CASE
Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation
Citation Text:
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - can contribute to delirium, hypotension, falls, and immobility along with its complications, such as pressure … ulcers and, as may have occurred in this case, aspiration pneumonia.
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - These
require SNFs to have measures in place to prevent specific clinical harms (such as falls, pressure … ulcers,
and health care–associated infections) and to improve medication management.
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psnet.ahrq.gov/periodic-issue/periodic-issue-413
October 31, 2023 - summarizes recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure … ulcers including recognition of conditional risks and educational strategies.
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Although differences have been
reported on patient variables like hospital-acquired pressure ulcers,
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psnet.ahrq.gov/issue/fall-related-injuries-acute-care-reducing-risk-harm
March 28, 2018 - June 5, 2019
Medical device-related pressure ulcers: a systematic review and meta-analysis
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psnet.ahrq.gov/issue/when-does-quality-improvement-count-research-human-subject-protection-and-theories-knowledge
July 10, 2019 - October 19, 2016
Organisational strategies to implement hospital pressure ulcer prevention
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psnet.ahrq.gov/curated-library/medicationdrug-errorsqqrysd
March 12, 2021 - hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure … ulcers.
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure … ulcers.