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psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm
June 01, 2016 - events, increased transparency in reporting of errors, and collaborative approaches to developing error prevention … January 23, 2019
Success in hospital-acquired pressure ulcer prevention: a tale in two
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - 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 … ulcers—that's too much for any human brain to handle. … ulcers, or most falls.
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psnet.ahrq.gov/node/60758/psn-pdf
August 05, 2020 - Decubitus ulcers were the most common diagnosis in
claims involving ICU nurses and compared to nurses … lessons-learned-medical-malpractice-claims-involving-critical-care-nurses
https://psnet.ahrq.gov/issue/crico
https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
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psnet.ahrq.gov/issue/more-1-million-potential-second-victims-how-many-could-nursing-education-prevent
May 30, 2018 - December 21, 2017
Organisational strategies to implement hospital pressure ulcer prevention
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - include delayed or omitted medications or
treatments; complications such as atelectasis, deconditioning, pressure … ulcers, falls, ventilator-associated
pneumonia, or other nosocomial infections; increased length of … significant impacts were demonstrated on medication errors, patient falls,
nosocomial infections, pressure … ulcers, mortality, and patient satisfaction. … Prevention
https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
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psnet.ahrq.gov/issue/potential-costs-and-consequences-associated-medication-error-hospital-discharge-expert
September 05, 2018 - July 24, 2019
Success in hospital-acquired pressure ulcer prevention: a tale in two data
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psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - Some
events, such as pressure ulcers in surgical patients, actually increased despite considerable national … https://psnet.ahrq.gov/glossary-0#glossary-heading-term-73754
https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero
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psnet.ahrq.gov/issue/accuracy-infection-reporting-us-nursing-home-ratings
August 24, 2022 - Download Citation
Related Resources From the Same Author(s)
Accuracy of pressure … ulcer events in US nursing home ratings. … COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention
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psnet.ahrq.gov/issue/human-right-based-approach-dealing-adverse-events-residential-care-facilities
May 27, 2011 - July 1, 2016
Tune-in and time-out: toward surgeon-led prevention of "never" events. … June 7, 2023
Accuracy of pressure ulcer events in US nursing home ratings.
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - include delayed or omitted medications or treatments; complications such as atelectasis, deconditioning, pressure … ulcers, falls, ventilator-associated pneumonia, or other nosocomial infections; increased length of … Statistically significant impacts were demonstrated on medication errors, patient falls, nosocomial infections, pressure … ulcers, mortality, and patient satisfaction. … Prevention The most consistent predictors of missed nursing care are staffing levels , work environment
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psnet.ahrq.gov/issue/preventing-catheter-related-bloodstream-infections-outside-intensive-care-unit-expanding
January 18, 2023 - Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention … Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention … Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention … August 21, 2018
Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.
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psnet.ahrq.gov/node/46041/psn-pdf
September 20, 2017 - retrospective-and
This economic analysis estimated the impact of nurse-sensitive adverse events—including pressure … ulcers,
falls, medication administration errors, pneumonia, and urinary tract infection—for the Canadian … more than 1300 excess hospital days per
year, and they advocate for more resources for adverse event prevention
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psnet.ahrq.gov/node/47349/psn-pdf
January 30, 2019 - 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. … //psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - ulcer or were put in physical restraints. … We looked at the outcomes on falls, pressure ulcers, and restraint use. … We
didn't find it for pressure ulcers. … ulcers. … But they are mainly medical-based outcomes or process-
based outcomes like pressure ulcers, use of restraints
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psnet.ahrq.gov/node/45511/psn-pdf
July 21, 2017 - Investigators compared a global measure of safety, which
included pressure ulcers, venous thromboembolism … preventability-hospital-acquired-venous-thromboembolism
https://psnet.ahrq.gov/primer/health-care-associated-infections
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
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psnet.ahrq.gov/issue/exploring-nursing-sensitive-events-home-healthcare-national-multicenter-cohort-study-using
August 05, 2020 - December 1, 2021
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Related Resources
The challenge of risk prevention … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors?
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psnet.ahrq.gov/issue/design-safe-or-sorry-study-cluster-randomised-trial-development-and-testing-evidence-based
May 22, 2013 - 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 . … July 16, 2013
Centers for Disease Control and Prevention Guideline for the Prevention
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - ulcers, and thromboembolic events) compared with patients operated on after 48 hours.(7)
Surgery for … anticoagulation management, early mobilization, and postdischarge care to optimize
secondary fracture prevention … ulcers, and significant functional decline. … outcomes and results in fewer
medical complications, including pneumonia, urinary tract infections, pressure … ulcers, and
thromboembolic events.
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psnet.ahrq.gov/primer/never-events
June 15, 2024 - associated with a fall while being cared for in a healthcare setting Any stage 3, stage 4, and unstageable pressure … ulcers acquired after admission/presentation to a healthcare setting Artificial insemination with the … April 17, 2013
Prevention of 3 "never events" in the operating room: fires, gossypiboma … See More About The Topic
Sentinel Event
Never Events
Hospitals
Operating Room
Pressure … Ulcers
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psnet.ahrq.gov/issue/estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-medical-and-surgical
July 11, 2018 - Root causes of adverse drug events in hospitals and artificial intelligence capabilities for prevention … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors?