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21. Early identification and evaluation of severe pressure injuries. | PSNet
    psnet.ahrq.gov/issue/early-identification-and-evaluation-severe-pressure-injuries
    October 10, 2018 - summarizes recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure … ulcers including recognition of conditional risks and educational strategies . … October 21, 2020 Proactive prevention of maternal death from maternal hemorrhage. … September 14, 2022 Accuracy of pressure ulcer events in US nursing home ratings. … Ulcers View More

22. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/49633/psn-pdf
    September 01, 2011 - For example, the rate of pressure ulcers in nursing homes has been shown to range between 2.2% to 23.9% … ulcer risk so that aggressive prevention strategies could have been put in place. … Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. … Reston, VA: National Pressure Ulcer Advisory Panel; 2001. 6. … RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse

23. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45147/psn-pdf
    May 25, 2016 - Are evidence-based practices associated with effective prevention of hospital-acquired pressure ulcers … Are Evidence-based Practices Associated With Effective Prevention of Hospital-acquired Pressure Ulcers … acquired-pressure Severe hospital-acquired pressure ulcers are considered a never event, and they result … ulcers in academic medical centers. … cmss-hospital-acquired-condition-lists-link-hospital-payment-patient-safety https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

24. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44953/psn-pdf
    March 09, 2016 - Students demonstrated a wide range of accuracy in identifying hazards, with fall risk most likely and pressure … ulcer risk least likely to be identified. … patient-safety-room-horrors-novel-method-assess-medical-students-and-entering-residents https://psnet.ahrq.gov/primer/simulation-training https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial … https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

25. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/854638/psn-pdf
    October 18, 2023 - summarizes recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure … ulcers including recognition of conditional risks and educational strategies. … early-identification-and-evaluation-severe-pressure-injuries https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis … https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review … https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program

26. Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis. | PSNet
    psnet.ahrq.gov/issue/evaluation-suitability-root-cause-analysis-frameworks-investigation-community-acquired
    June 16, 2021 - ulcers . … In hospital and long-term care settings, pressure ulcers are considered preventable complications, but … August 14, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis … October 8, 2016 Wound-care teams for preventing and treating pressure ulcers. … November 12, 2014 Preventing in-facility pressure ulcers as a patient safety strategy

27. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45533/psn-pdf
    November 02, 2016 - improvement project in the United Kingdom to address four patient safety issues: venous thromboembolism, pressure … ulcers, catheter–associated urinary tract infections, and falls. … preventability-hospital-acquired-venous-thromboembolism https://psnet.ahrq.gov/issue/organisational-strategies-implement-hospital-pressure-ulcer-prevention-programmes-findings … program-prevent-catheter-associated-urinary-tract-infection-acute-care https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial

28. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45202/psn-pdf
    October 08, 2016 - psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury- policy Pressure … ulcers are never events that continue to occur, despite potential repercussions on reimbursement. … towards-international-consensus-patient-harm-perspectives-pressure-injury-policy https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review … impact-hospital-acquired-conditions-medicare-program-payments https://psnet.ahrq.gov/issue/are-evidence-based-practices-associated-effective-prevention-hospital-acquired-pressure

29. Medical device-related pressure ulcers: a systematic review and meta-analysis. | PSNet
    psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis
    March 10, 2021 - Review Classic Medical device-related pressure ulcers: … Medical device-related pressure ulcers: A systematic review and meta-analysis. … Hospital-acquired pressure ulcers are considered never events and represent a significant source of … Medical device-related pressure ulcers: A systematic review and meta-analysis.

30. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42113/psn-pdf
    March 20, 2013 - Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. … Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. … https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review … Pressure ulcers are considered a never event, but their incidence has been increasing despite effective … , and regular audit and feedback of pressure ulcer rates in ensuring intervention success.

31. Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice. | PSNet
    psnet.ahrq.gov/issue/barriers-and-facilitators-reporting-medical-device-related-pressure-ulcers-qualitative
    April 07, 2019 - Study Barriers and facilitators to reporting medical device-related pressure ulcers … Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration … Hospital-acquired pressure ulcers, categorized as a never event, are underreported , particularly when … Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting … Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration

32. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44525/psn-pdf
    October 21, 2015 - Wound-care teams for preventing and treating pressure ulcers. … Wound-care teams for preventing and treating pressure ulcers. … https://psnet.ahrq.gov/issue/wound-care-teams-preventing-and-treating-pressure-ulcers Pressure ulcers … https://psnet.ahrq.gov/issue/wound-care-teams-preventing-and-treating-pressure-ulcers https://psnet.ahrq.gov … /issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review https://psnet.ahrq.gov

33. Patient Safety Indicators at an academic veterans affairs hospital: addressing dual goals of clinical care and validity. | PSNet
    psnet.ahrq.gov/issue/patient-safety-indicators-academic-veterans-affairs-hospital-addressing-dual-goals-clinical
    August 09, 2023 - accurate data capture interventions to improve rates of the composite PSI-90 and three individual PSIs ( pressure … ulcers , postoperative PE/DVT, and postoperative sepsis). … Postoperative PE/DVT, postoperative sepsis, and composite PSI-90 all decreased, while pressure ulcer … Related Resources From the Same Author(s) Assessment of a wearable fall prevention … Ulcers View More

34. Enhancing Patient Safety and Outcomes: The Safe Patient Handling Connection. | PSNet
    psnet.ahrq.gov/issue/enhancing-patient-safety-and-outcomes-safe-patient-handling-connection
    September 23, 2021 - Patient handling can affect the safety of patient mobility , development of pressure ulcers and worker … Term Care September 1, 2011 Applying High Reliability Principles to Infection Prevention … View More See More About Online Education Nursing Latent Errors Pressure … Ulcers Patient Falls View More

35. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/37270/psn-pdf
    January 02, 2017 - Preventing pressure ulcers: the goal is zero. January 2, 2017 Duncan KD. … Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007;33(10):605-10. … https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero This article discusses the background … and motivation behind the 5 Million Lives Campaign goal to prevent and eliminate pressure ulcers. … https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero https://psnet.ahrq.gov/issue/5-million-lives-campaign

36. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38625/psn-pdf
    November 19, 2009 - randomised trial on the development and testing of an evidence based inpatient safety program for the prevention … randomised trial on the development and testing of an evidence based inpatient safety program for the prevention … implementation of a patient safety program focused on evidence-based guidelines to reduce the incidence of pressure … ulcers, falls, and urinary tract infections. … making-health-care-safer-critical-analysis-patient-safety-practices https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero

37. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43524/psn-pdf
    October 29, 2014 - study found that diagnostic codes in administrative data for hospital-related complications such as pressure … ulcers, falls, and adverse drug events accurately reflect the presence of these events in the medical … validating-administrative-data-detection-adverse-events-older-hospitalized-patients https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review … https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial https://psnet.ahrq.gov

38. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43125/psn-pdf
    December 12, 2014 - authors attribute improvements to systems strategies, including checklists, safety culture surveys, and prevention … of pressure ulcers and infections. … checklists https://psnet.ahrq.gov/primer/culture-safety https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

39. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/47788/psn-pdf
    March 06, 2019 - Medical device-related pressure ulcers: a systematic review and meta-analysis. … Medical device-related pressure ulcers: A systematic review and meta-analysis. … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis … Hospital-acquired pressure ulcers are considered never events and represent a significant source of … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis

40. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
    September 01, 2011 - Unfortunately, likely secondary to an infection of the pressure ulcer, she developed septic shock and … Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. … Reston, VA: National Pressure Ulcer Advisory Panel; 2001. … RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse … Organizations can monitor their rates of falls, pressure ulcers, infections, unplanned hospitalizations