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201. An integrative review exploring the perceptions of patients and healthcare professionals towards patient involvement in promoting hand hygiene compliance in the hospital setting. | PSNet
     psnet.ahrq.gov/issue/integrative-review-exploring-perceptions-patients-and-healthcare-professionals-towards
     March 06, 2019 - Citation Related Resources From the Same Author(s) Medical device-related pressure … ulcers: a systematic review and meta-analysis.

202. Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era. | PSNet
     psnet.ahrq.gov/issue/reliability-uncertainty-and-management-error-new-perspectives-covid-19-era
     January 12, 2022 - July 15, 2009 Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.

203. Association between hospital acquired harm outcomes and membership in a national patient safety collaborative. | PSNet
     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

204. Situation awareness and the mitigation of risk associated with patient deterioration: a meta-narrative review of theories and models and their relevance to nursing practice. | PSNet
     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

205. Breathe Easy: Safe Tracheostomy Management | PSNet
     psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
     June 07, 2023 - Tracheostomy devices can cause pressure ulcers, particularly along the inferior aspect of the tracheostomy … skin-barrier dressing under the tracheostomy faceplate, can reduce the incidence of tracheostomy-related pressure … ulcers. … September 23, 2020 Patient and caregiver perspectives on causes and prevention of ambulatory

206. Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. | PSNet
     psnet.ahrq.gov/issue/learning-preventable-deaths-exploring-case-record-reviewers-narratives-using-change-analysis
     June 17, 2014 - Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure … ulcers: a systematic review and documentary analysis.

207. Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/effect-world-health-organization-checklist-patient-outcomes-stepped-wedge-cluster-randomized
     June 03, 2020 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors?

208. Third Annual Report on Adverse Health Events in Wyoming Healthcare Facilities. | PSNet
     psnet.ahrq.gov/issue/third-annual-report-adverse-health-events-wyoming-healthcare-facilities
     October 11, 2016 - Executives and Administrators Policy Makers Medication Errors/Preventable Adverse Drug Events Pressure … Ulcers View More

209. In Conversation with…Robert M. Wachter, MD | PSNet
     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

210. The $17.1 billion problem: the annual cost of measurable medical errors. | PSNet
     psnet.ahrq.gov/issue/171-billion-problem-annual-cost-measurable-medical-errors
     May 26, 2021 - billion, largely attributable to post-surgical complications, health care–associated infections , and pressure … ulcers.

211. Legislative Report to the General Assembly: Adverse Event Reporting. | PSNet
     psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting
     May 20, 2009 - The most common adverse events reported were pressure ulcers and fall-related injuries or deaths .

212. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer. | PSNet
     psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010-2015-interim-data-national-efforts
     December 24, 2008 - tract infections , central line–associated bloodstream infections , falls, obstetric adverse events, pressure … ulcers, surgical site infections, ventilator-associated pneumonias, and postoperative venous thromboembolisms

213. Do safety briefings improve patient safety in the acute hospital setting? A systematic review. | PSNet
     psnet.ahrq.gov/issue/do-safety-briefings-improve-patient-safety-acute-hospital-setting-systematic-review
     August 14, 2024 - July 5, 2017 Wound-care teams for preventing and treating pressure ulcers.

214. Validating administrative data for the detection of adverse events in older hospitalized patients. | PSNet
     psnet.ahrq.gov/issue/validating-administrative-data-detection-adverse-events-older-hospitalized-patients
     March 13, 2015 - 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

215. Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis. | PSNet
     psnet.ahrq.gov/issue/identifying-list-healthcare-never-events-effect-system-change-systematic-review-and-narrative
     April 24, 2019 - April 3, 2024 Medical device-related pressure ulcers: a systematic review and meta-analysis

216. Effects of computerized decision support system implementations on patient outcomes in inpatient care: a systematic review. | PSNet
     psnet.ahrq.gov/issue/effects-computerized-decision-support-system-implementations-patient-outcomes-inpatient-care
     November 06, 2019 - effective for managing blood glucose and blood transfusions and for preventing venous thromboembolism , pressure … ulcers , acute kidney injury, and incipient clinical deterioration.

217. Nursing and Patient Safety | PSNet
     psnet.ahrq.gov/primer/nursing-and-patient-safety
     September 15, 2024 - However, the key findings in a recent integrative review include fewer pressure ulcers and urinary tract … workplace, more nurses are likely to self-report missed nursing care. 11   When evaluating cause and prevention … included patient-centered outcomes considered to be markers of nursing care quality (such as falls and pressure … ulcers) and system-related measures including nursing skill mix, nursing care hours, measures of the

218. How to make medication error reporting systems work—factors associated with their successful development and implementation. | PSNet
     psnet.ahrq.gov/issue/how-make-medication-error-reporting-systems-work-factors-associated-their-successful
     December 05, 2012 - Related Resources Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.

219. Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. | PSNet
     psnet.ahrq.gov/issue/adverse-events-rehabilitation-hospitals-national-incidence-among-medicare-beneficiaries
     January 09, 2019 - Nearly half of the events were considered preventable, with the most common types of events including pressure … ulcers, delirium, and medication errors .

220. From research to practice: factors affecting implementation of prospective targeted injury-detection systems. | PSNet
     psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
     August 04, 2021 - five hospitals faced in implementing new systems for prospective detection of adverse drug events and pressure … ulcers, and recommends steps organizations can take to ensure smoother implementation.