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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - a fully closed system that collects and contains liquid or semi-liquid stools and can assist in the prevention
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psnet.ahrq.gov/issue/estimating-hospital-costs-inpatient-harms
February 07, 2024 - Pressure ulcers, surgical site infections , and other hospital-acquired conditions are common preventable
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - Our hospitals have great protocols in place for pressure injury prevention, but prone positioning brought … They had been a common strategy for fall prevention, but with the requirement to put on PPE, there was … We also experienced, as Rhonda mentioned, difficulties with pressure ulcer prevention and timely response … For example, the Centers for Disease Control and Prevention has produced guidance for optimizing PPE … of pressure injuries , all of which are specifically focused on harm prevention in COVID-19 patients
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - For example, the Centers for Disease Control and Prevention has produced guidance for optimizing PPE … of pressure injuries , all of which are specifically focused on harm prevention in COVID-19 patients … Our hospitals have great protocols in place for pressure injury prevention, but prone positioning brought … They had been a common strategy for fall prevention, but with the requirement to put on PPE, there was … We also experienced, as Rhonda mentioned, difficulties with pressure ulcer prevention and timely response
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psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
July 10, 2024 - August 7, 2019
Medical device-related pressure ulcers: a systematic review and meta-analysis
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psnet.ahrq.gov/issue/national-patient-safety-goals
May 30, 2012 - infections , medication errors, inpatient suicide , and specific clinical harms such as falls and pressure … ulcers.
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psnet.ahrq.gov/issue/instruments-and-warning-signs-identifying-and-evaluating-frequency-adverse-events
July 20, 2022 - Common adverse events impacting this population include adverse drug events, delirium , malnutrition, pressure … ulcers, and infections.
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psnet.ahrq.gov/issue/impact-team-and-leaders-directed-strategy-improve-nurses-adherence-hand-hygiene-guidelines
November 19, 2009 - randomised trial on the development and testing of an evidence based inpatient safety program for the prevention … August 27, 2008
Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.
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psnet.ahrq.gov/issue/survey-hospital-quality-improvement-activities
January 27, 2019 - Related Resources
A comprehensive program to reduce rates of hospital-acquired pressure … ulcers in a system of community hospitals. … influence of organizational context on quality improvement and patient safety efforts in infection prevention
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psnet.ahrq.gov/issue/situation-awareness-and-mitigation-risk-associated-patient-deterioration-meta-narrative
December 08, 2021 - August 3, 2022
Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice. … November 24, 2021
Prevention of failure to rescue in obstetric patients: a realist review
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psnet.ahrq.gov/issue/association-between-hospital-acquired-harm-outcomes-and-membership-national-patient-safety
June 29, 2022 - September 2, 2020
Evaluation of clinical practice guidelines on fall prevention and management … Children's Hospitals
Pediatrics
Indwelling Tubes and Catheters
Nosocomial Infections
Pressure … Ulcers
View More
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psnet.ahrq.gov/issue/rethinking-hospital-restraints
May 04, 2011 - patients from harm, this magazine article highlights risks related to their use—such as increased rates of pressure … ulcers and delirium—and advocates for a more patient-sensitive approach to ensure the safety of both
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psnet.ahrq.gov/issue/implementation-centers-medicare-medicaid-services-nonpayment-policy-preventable-hospital
September 16, 2020 - The study looked at four nursing-sensitive adverse outcomes: pressure ulcers, falls with injuries, catheter-associated
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psnet.ahrq.gov/issue/multimethod-study-large-scale-programme-improve-patient-safety-using-harm-free-care-approach
January 23, 2019 - improvement project in the United Kingdom to address four patient safety issues: venous thromboembolism , pressure … ulcers , catheter–associated urinary tract infections , and falls .
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psnet.ahrq.gov/issue/preventable-and-mitigable-adverse-events-cancer-care-measuring-risk-and-harm-across-continuum
July 19, 2017 - Adverse events included medication errors and hospital-acquired conditions , such as pressure ulcers
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psnet.ahrq.gov/issue/learning-and-mindfulness-improving-perioperative-patient-safety
January 12, 2022 - January 23, 2008
Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.
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psnet.ahrq.gov/issue/economic-measurement-medical-errors
March 23, 2022 - The most common preventable errors were pressure ulcers—considered a never event —and health care–associated
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psnet.ahrq.gov/node/47328/psn-pdf
January 01, 2020 - Overall, HAC rates declined
over the 2 years following implementation of the program, with only rates of pressure … ulcers increasing.
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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
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psnet.ahrq.gov/issue/nhs-safety-thermometer-report-patient-harms-and-harm-free-care-november-2014-november-2015
July 08, 2021 - report collection explores the data collected on four types of health care–acquired conditions ( pressure … ulcers , falls, catheter–associated urinary tract infections, and venous thromboembolisms ) in NHS