- 
                                        
psnet.ahrq.gov/node/47093/psn-pdf
July 02, 2019 - effective for managing blood glucose and blood transfusions
and for preventing venous thromboembolism, pressure … ulcers, acute kidney injury, and incipient clinical
deterioration.
                                     
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psnet.ahrq.gov/issue/impact-hospital-acquired-conditions-medicare-program-payments
November 18, 2016 - evaluated costs related to the index hospitalization and 90 days following discharge of six HACs—severe pressure … ulcers, fractures, catheter-associated urinary tract infections, venous catheter-related infections, … Severe  pressure ulcers  and orthopedic surgical site infections resulted in an average increase in payments
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/patient-safety-palliative-care-mixed-methods-study-reports-national-database-serious
May 16, 2018 - They found that pressure ulcers, medication errors, and falls were the most frequently reported types … More About The Topic 
 
    Long-Term Care 
  Facility and Group Administrators 
  Palliative Care 
  Pressure … Ulcers 
  Patient Falls 
 
 
 
 View More
                                     
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psnet.ahrq.gov/issue/facility-delirium-programs-patient-safety-strategy-systematic-review
March 13, 2013 - January 6, 2018 
 
 
 
 
 
 
 
 Preventing in-facility pressure ulcers as a patient safety strategy: … May 1, 2016 
 
 
 
 
 
 
 
 Preventing in-facility pressure ulcers as a patient safety strategy: a systematic
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/implementing-electronic-root-cause-analysis-reporting-system-decrease-hospital-acquired
December 22, 2021 - See More About The Topic 
 
    Hospitals 
  Quality and Safety Professionals 
  Nurse Care 
  Pressure … Ulcers 
  Latent Errors 
 
 
 
 View More
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/harm-free-care
April 15, 2020 - This initiative seeks to reduce four key sources of harm in hospitals: pressure ulcers, falls, catheter-associated
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/rates-adverse-events-hospitalized-patients-after-summer-time-resident-changeover-united
June 22, 2022 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors? … Hospitals 
  Medicine 
  Medication Errors/Preventable Adverse Drug Events 
  Nosocomial Infections 
  Pressure … Ulcers 
 
 
 
 View More
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/41367/psn-pdf
May 09, 2012 - psnet.ahrq.gov/issue/harm-free-care
This initiative seeks to reduce four key sources of harm in hospitals: pressure … ulcers, falls, catheter-
associated urinary tract infections, and vascular thrombotic events.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary-0
October 23, 2019 - highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure … ulcer while in the hospital.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - ulcers—that's too much for any human brain to handle. … ulcers, or most falls. … ulcers in addition to stage 3 or 4 ulcers acquired after admission. … ulcer (codes 707.00–707.09). … Our administrative system has a limitation of 15 diagnoses, and it is possible that the decubitus ulcer
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence
August 25, 2021 - Intensive Care Units 
  Quality and Safety Professionals 
  Public Health 
  Infectious Diseases 
  Pressure … Ulcers 
 
 
 
 View More
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/mindful-path-nursing-accuracy-quasi-experimental-study-minimizing-medication-administration
March 03, 2019 - August 26, 2020 
 
 
 
 
 
 
 
 Organisational strategies to implement hospital pressure ulcer prevention
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize
August 24, 2011 - February 5, 2020 
 
 
 
 
 
 
 
 Accuracy of pressure ulcer events in US nursing home ratings.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - View More 
 
 
 
 
 
 Related Resources 
 
 
 
 
 
 
 Organisational strategies to implement hospital pressure … ulcer prevention programmes: findings from a national survey.
                                     
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - include delayed or omitted medications or
treatments; complications such as atelectasis, deconditioning, pressure … ulcers, falls, ventilator-associated
pneumonia, or other nosocomial infections; increased length of … significant impacts were demonstrated on medication errors, patient falls,
nosocomial infections, pressure … ulcers, mortality, and patient satisfaction.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/41882/psn-pdf
November 28, 2012 - commentary describes the design and initial test of a large-scale initiative to track incidents involving
pressure … ulcers, falls, urinary infections in patients with catheters, and venous thromboembolism in the
National
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/46892/psn-pdf
June 13, 2018 - While infections and adverse drug events decreased, pressure ulcers increased and
represent an opportunity
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-rape-dont-dock-five
December 22, 2021 - March 29, 2023 
 
 
 
 
 
 
 
 Accuracy of pressure ulcer events in US nursing home ratings.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/front-line-defense-role-nurses-preventing-sentinel-events-third-edition
November 27, 2018 - December 15, 2017 
 
 
 
 
 
 
 
 Organisational strategies to implement hospital pressure ulcer prevention
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/35088/psn-pdf
January 01, 2025 - hospital-acquired infections, medication errors, inpatient
suicide, and specific clinical harms such as falls and pressure … ulcers.