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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - pulse oximetry monitoring, wound care, blood draws, intravenous catheter placement,
skin care and prevention … of pressure ulcers, respiratory and ventilator support, and correct administration of
medications can
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - They're getting decubitus ulcers.
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common?
Mark L. Graber, MD | February 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpi…
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - Intramuscular injection site injuries masquerading as pressure ulcers. Wounds. 2003;15:302-312. … Smoking cessation advice/counseling Appropriate Initial Antibiotic Selection Surgical Infection Prevention
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - influence of culture comes from the Rhode Island intensive care unit (ICU) collaborative that worked on the prevention … because they are able to do the basics every time, like turning patients every 60 minutes to avoid pressure … ulcers, using a central line checklist, or washing their hands frequently.
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - This makes it necessary to have patient safety practices directed specifically at prevention in these … is that there are four risk factors that underlie many of our hospital acquired conditions, (i.e., pressure … ulcers and catheter associated infections, falls, and delirium). … Whereas, working on mobility, delirium prevention, skin care, etc. is a more horizontal cross-cutting … We placed fall prevention above safe mobility.
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - is that there are four risk factors that underlie many of our hospital acquired conditions, (i.e., pressure … ulcers and catheter associated infections, falls, and delirium). … Whereas, working on mobility, delirium prevention, skin care, etc. is a more horizontal cross-cutting … In the health system I’m at right now, we’re increasingly marrying our falls prevention work with our … We placed fall prevention above safe mobility.
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psnet.ahrq.gov/topics-0
March 03, 2025 - Nosocomial Infections Go to this topic
Patient Falls Go to this topic
Pressure … Ulcers Go to this topic
Venous Thrombosis and Thromboembolism Go to this topic
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - kernicterus) associated with failure to identify and treat
hyperbilirubinemia in neonates
Stage 3 or 4 pressure … ulcers acquired after admission to a health care facility
Patient death or serious disability due to
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - States, we have since
experienced higher rates of preventable infections, as well as increases in pressure … ulcers and falls. … dynamic reality, reorienting focus from performance measures of harm to measures that
reflect risk prevention … nursing homes across the United States to increase the implementation
of evidence-based infection prevention … with our work to radically reorient our thinking and approach to safety to place more emphasis on
prevention
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - Various strategies are used for fall prevention in the hospital. … serious problem in the hospital, putting patients at risk for many other problems, including delirium, pressure … ulcers, and functional decline. … Guideline for the prevention of falls in older persons. … Do hospital fall prevention programs work? A systematic review.
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Various strategies are used for fall prevention in the hospital. … serious problem in the
hospital, putting patients at risk for many other problems, including delirium, pressure … ulcers, and functional
decline. … Guideline for the prevention of falls in older persons. … Do hospital fall prevention programs work? A systematic review.
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - They're getting decubitus ulcers.
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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Complications
(4)
Nosocomial Infections
(4)
Patient Falls
(1)
Pressure … Ulcers
(1)
Medication Safety
(6)
Medication Errors/Preventable Adverse
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - May 8, 2017
Perspective
How Does Infection Prevention Fit
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Influential research products include over 100 evidence-based national quality, prevention, and safety … substances, reduction of hospital-acquired conditions, voluntary events reporting, and loss control/prevention … such as surgery, obstetrics, hospital-associated infections, emergency departments, sepsis, falls, pressure … ulcers, venous thromboembolism, and care transitions. … safety, infusion safety, clinical alarms safety, unit-based safety improvement, venous thromboembolism prevention
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - They're getting decubitus ulcers.
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - Overload
November 1, 2012
Are evidence-based practices associated with effective prevention … of hospital-acquired pressure ulcers in US academic medical centers?
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psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - Or a patient falls or gets what might be a preventable pressure ulcer, or a mistake occurs in a
surgical