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241. Implementation of the safety huddle. | PSNet
     psnet.ahrq.gov/issue/implementation-safety-huddle
     November 03, 2021 - July 19, 2023 A comprehensive program to reduce rates of hospital-acquired pressure ulcers

242. Relationship of staff information sharing and advice networks to patient safety outcomes. | PSNet
     psnet.ahrq.gov/issue/relationship-staff-information-sharing-and-advice-networks-patient-safety-outcomes
     June 22, 2011 - networks on several patient safety outcomes, including medication errors , falls , and hospital-acquired pressure … ulcers, across 24 medical and surgical inpatient units at 3 hospitals.

243. "SWARMing" to improve patient care: a novel approach to root cause analysis. | PSNet
     psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis
     September 23, 2020 - Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure … ulcers: a systematic review and documentary analysis.

244. Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review. | PSNet
     psnet.ahrq.gov/issue/medicines-related-problems-mrps-originating-primary-care-settings-older-adults-systematic
     March 04, 2015 - Clinic or Office Primary Care Geriatrics Medication Errors/Preventable Adverse Drug Events Pressure … Ulcers View More

245. The Forgotten Line | PSNet
     psnet.ahrq.gov/web-mm/forgotten-line
     March 11, 2011 - We now know differently: the Centers for Disease Control and Prevention (CDC) recently reported a 58% … 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. … Centers for Disease Control and Prevention. … Summary of recommendations: guidelines for the prevention of intravascular catheter-related infections

246. Too Many Cooks in the Kitchen | PSNet
     psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
     March 07, 2018 - Prolonged hospital bedrest leads to loss of muscle and bone mass and increases the risk of pressure ulcers … Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam Dressings. 

247. Adverse events in long-term care residents transitioning from hospital back to nursing home. | PSNet
     psnet.ahrq.gov/issue/adverse-events-long-term-care-residents-transitioning-hospital-back-nursing-home
     April 28, 2021 - Common adverse events included falls , pressure ulcers, health care–associated infections , and adverse

248. Patient safety and workplace bullying: an integrative review. | PSNet
     psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-review
     March 11, 2020 - February 7, 2024 View More Related Resources Medical device-related pressure … ulcers: a systematic review and meta-analysis.

249. Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. | PSNet
     psnet.ahrq.gov/issue/making-health-care-safer-ii-updated-critical-analysis-evidence-patient-safety-practices
     March 13, 2013 - wide range of safety threats, including health care–associated infections , medication errors , and pressure … ulcers.

250. National trends in patient safety for four common conditions, 2005–2011. | PSNet
     psnet.ahrq.gov/issue/national-trends-patient-safety-four-common-conditions-2005-2011
     August 03, 2016 - Some events, such as pressure ulcers in surgical patients, actually increased despite considerable

251. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33597/psn-pdf
     April 10, 2024 - safety issues were revealed, particularly around the weakness in nursing home infection control and prevention … the biggest surge of COVID-19 cases since the end of the pandemic, despite several safeguards and prevention … , including recent programs in response to the COVID-19 pandemic such as, an infection control and prevention … These require SNFs to have measures in place to prevent specific clinical harms (such as falls, pressure … ulcers, and health care–associated infections) and to improve medication management.

252. Online medication error graphic reports: a pilot in North Carolina nursing homes. | PSNet
     psnet.ahrq.gov/issue/online-medication-error-graphic-reports-pilot-north-carolina-nursing-homes
     March 24, 2011 - June 7, 2023 Accuracy of pressure ulcer events in US nursing home ratings.

253. Impact of date stamping on patient safety measurement in patients undergoing CABG: experience with the AHRQ Patient Safety Indicators. | PSNet
     psnet.ahrq.gov/issue/impact-date-stamping-patient-safety-measurement-patients-undergoing-cabg-experience-ahrq
     December 21, 2014 - Hospitals Quality and Safety Professionals General Internal Medicine Hospital Medicine Pressure … Ulcers View More

254. Understanding national coverage policies. Navigating the maze of HACs, serious reportable events, and wrong surgical sites. | PSNet
     psnet.ahrq.gov/issue/understanding-national-coverage-policies-navigating-maze-hacs-serious-reportable-events-and
     June 28, 2017 - The Topic Hospitals Health Care Executives and Administrators Nosocomial Infections Pressure … Ulcers Venous Thrombosis and Thromboembolism View More

255. Views of nurses and other health and social care workers on the use of assistive humanoid and animal-like robots in health and social care: a scoping review. | PSNet
     psnet.ahrq.gov/issue/views-nurses-and-other-health-and-social-care-workers-use-assistive-humanoid-and-animal
     July 27, 2022 - February 24, 2022 - February 24, 2022 Medical device-related pressure ulcers: a systematic

256. Interventions to increase patient safety in long-term care facilities-umbrella review. | PSNet
     psnet.ahrq.gov/issue/interventions-increase-patient-safety-long-term-care-facilities-umbrella-review
     September 01, 2021 - February 15, 2023 Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.

257. Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment. | PSNet
     psnet.ahrq.gov/issue/modifying-head-nurse-messages-during-daily-conversations-leverage-safety-climate-improvement
     August 26, 2011 - June 18, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

258. Barriers and facilitators to incident reporting in mental healthcare settings: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/barriers-and-facilitators-incident-reporting-mental-healthcare-settings-qualitative-study
     February 05, 2020 - August 25, 2021 Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.

259. Investigation of mental and physical health of nurses associated with errors in clinical practice. | PSNet
     psnet.ahrq.gov/issue/investigation-mental-and-physical-health-nurses-associated-errors-clinical-practice
     September 21, 2022 - Related Resources Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.

260. SNFs: Opening the Black Box | PSNet
     psnet.ahrq.gov/web-mm/snfs-opening-black-box
     August 27, 2012 - can contribute to delirium, hypotension, falls, and immobility along with its complications, such as pressure … ulcers and, as may have occurred in this case, aspiration pneumonia. … August 20, 2018 Evaluation of clinical practice guidelines on fall prevention and management … Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention