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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
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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/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - made in the past 10 years—improvements in healthcare-acquired infections, decreases in patient falls, pressure … 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%. … ulcers. 14 Healthcare leaders recognize the need to do better.
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www.ahrq.gov/sites/default/files/2024-07/alexander-report.pdf
January 01, 2024 - sores; 4) who are at low risk and who
have pressure sores; 5) who are physically restrained; 6) who … sores. … Ulcers 13938 787 5.9 5.6
Who Lose Too Much Weight 14183 798 7.4 7.5
Bowel or Bladder Incontinent 13038 … Ulcers -0.01 -0.05 0.01 0.05 0.02 0.04 0.05 0.02 -0.01 0.01
Who Lose Too Much Weight 0.05 0.05 0.05 … Ulcers, and % Short Stay
Assessed/Given Pneumococcal Vaccine.
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/osteoarthritis-pain-disposition-120516.pdf
October 01, 2011 - Comparative Effectiveness and Safety of Analgesics for Osteoarthritis—An Update of the 2006 Report.
Source: http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-
reports/?productid=494&pageaction=displayproduct
Published Online: August 2010
Comparative Effectiveness Research Re…
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hcup-us.ahrq.gov/reports/methods/2012-02.pdf
January 01, 2012 - ulcers – Stage III or IV – per 1,000 discharges of length 5 or more daysa (excluding
neonates; transfers … ulcers – Stage III or IV – per 1,000 discharges of length 5 or more days (excluding transfers;
patients … ulcers, such as cases from earlier admissions or
from other hospitals. … Ulcer
• PSI 6 Iatrogenix Pneumothorax
• PSI 7 Central Venous Catheter-Related Bloodstream Infection … Ulcer
• PDI 5 Pediatric: Iatrogenic Pneumothorax
• PDI 8 Pediatric: Postoperative Hemorrhage or
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/preventablehospitalandedvisits-implmatl.pdf
June 03, 2025 - status
Oxygen dependency
Confusion/mental status change
Any full thickness wound (e.g., pressure … ulcers [Stage II or greater], surgical
wound, stasis ulcer)
Polypharmacy (15 or more medications … Chronic pressure ulcers Yes No
L. Recurrent UTI Yes No
M. Anemia Yes No
N.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
June 12, 2008 - taxonomies include mistakes (e.g., prescribing errors) and the outcome of mistakes (e.g., p
falls, decubitus … ulcers) as event types. … However, falls and decubitus ulcers are visible ha
(outcomes) that might have resulted from failure to … the proportion of
incidents in the ICUSRS with harm identified, it is not surprising that falls and decubitus … ulcers
were among the highest.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/laparotomy-patient.pdf
November 01, 2023 - Recovering After Emergency Laparotomy
Recovering After
Emergency Laparotomy
e
Emergency Laparotomy Patient Education Guide 1
Recovering After Emergency
Laparotomy
Patient Name ___________________________________________________________________
Surgeon Name ________________________________________________…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-slides.pptx
January 01, 2017 - Estimated Additional Costs of Healthcare-Acquired Conditions (HACs)
Series 1 VAPs SSIs CLABSI Other HACs Pressure … Ulcers Post-op DVTs Falls Adverse Drug Events Obstetric Adverse Events CAUTI 21001 21000 17000 17000 … Sheet1
Series 1
VAPs $ 21,001
SSIs $ 21,000
CLABSI $ 17,000
Other HACs $ 17,000
Pressure … Ulcers $ 17,000
Post-op DVTs $ 8,000
Falls $ 7,234
Adverse Drug Events $ 5,000
Obstetric
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Savitz.pdf
March 01, 2004 - overarching indicators related to medication
administration errors, nosocomial infections, patient falls, pressure … ulcers, and
mortality, with increasing detail in measure specification.11 For example,
nosocomial … accepted
n=7)
Provisional NQF
(n=13)
ANA
(n=10)
Death in low mortality DRG X
Decubitus/pressure … ulcer X X X
Failure to rescue X X X
Infection due to medical care X
• Urinary tract infection … We see virtually no direct overlap in these
measure sets, with the exception of decubitus/pressure ulcer
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/disabilities-quality-improvement-outcomes_research-protocol.pdf
August 03, 2011 - Preventive
Services Task Force)
o Urinary tract infections
o Pressure ulcers
o Uncontrolled diabetes … 14. 9 and 13 4943
15. limit 14 to (english language and yr="1990 -Current") 3663
KQ 1b Pressure … ulcer example search
1. exp Disabled Persons/ 39840
2. exp mental disorders diagnosed in … . intellectual disabilit$.mp. 3092
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 214730
10. exp Pressure … Ulcer/ 8794
11. 9 and 10 120
KQs 2 and 3 Coordinated care example search
1. exp Disabled
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hcup-us.ahrq.gov/reports/methods/2012_03.pdf
January 01, 2012 - ulcers – Stage III or IV – per 1,000 discharges of length 5 or more days (excluding neonates;
transfers … ulcers – Stage III or IV – per 1,000 discharges of length 5 or more days (excluding transfers;
patients … ulcers, such as cases from earlier admissions or
from other hospitals. … Ulcer
• PSI 6 Iatrogenix Pneumothorax
• PSI 7 Central Venous Catheter-Related Bloodstream Infection … Ulcer
• PDI 5 Pediatric: Iatrogenic Pneumothorax
• PDI 8 Pediatric: Postoperative Hemorrhage or
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/section4.html
October 01, 2015 - associated with many infectious and noninfectious complications including immobility (with potential pressure … ulcers and increased risk for thromboembolism), trauma, and debility.
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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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www.ahrq.gov/research/findings/final-reports/index.html?page=3
January 01, 2024 - Grant Number: R01 HS 22903 Topic(s): Pressure Ulcers Publication Date: June 2020
Occult Uterine
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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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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/screening-for-prediabetes-and-type-2-diabetes
November 15, 2018 - Share to Facebook
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Final Research Plan
Prediabetes and Type 2 Diabetes: Screening
November 15, 2018
Recommendations made by the USPSTF are independent of the U.S. government. They should not be …