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421. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - There are no detailed sections for the Perinatal, Pressure Ulcer, or Surgery or Anesthesia EVENT TYPES … No harm was reported for more than one-quarter (18,632 / 73,155; 25.5%) of Pressure Ulcer Incidents … This was unexpected, as pressure ulcers, like HAIs and venous thromboembolism (VTE), result in harm … Ulcer A pressure ulcer that, on admission, was at stage/category III or stage/category IV or was … /category I or stage/category II A pressure ulcer whose most advanced stage is unknown A mucosal

422. Psn-Pdf (pdf file)
     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

423. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - ulcer (bed sores); or postoperative sepsis (blood infection). … Decubitus ulcer 5. Failure to rescue 6. Foreign body left during procedure 7. … • Monitoring errors, such as bedsores, failure to rescue, and patient falls. … ulcer monitoring error • Increased checking of inpatients for decubitus ulcers • Monitoring … forms or behavioral checklists • Decubitus ulcer incidence rate feedback • Supervisor praise

424. Never Events | PSNet
     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 View More

425. An Example of Using Present on Admission Data: CMS-Defined Hospital-Acquired Conditions in All-Payer Data
     hcup-us.ahrq.gov/datainnovations/clinicaldata/ExampleofUsingPOA-CMSHACsusingall-payerdata.jsp
     August 01, 2011 - ulcers (66 percent). … ulcer and 18 percent had manifestations of poor glycemic control CMS HACs. … Stage 3 and 4 pressure ulcers: private insurance: 0.32; Medicaid: 1.25. … Stage 3 and 4 pressure ulcers: 45-64 year olds: 1.44; 65-84 year olds: 2.18; 85 years and older: 2.57 … Ulcers are: 707.23, pressure ulcer, stage III 707.24, pressure ulcer, stage IV The ICD-9-

426. Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool. | PSNet
     psnet.ahrq.gov/issue/exploring-nursing-sensitive-events-home-healthcare-national-multicenter-cohort-study-using
     August 05, 2020 - December 1, 2021 View More Related Resources The challenge of risk prevention … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors?

427. The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. | PSNet
     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

428. Board and Senior Leadership PowerPoint Presentations on the Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
     October 01, 2015 - ulcer) • Denominator = population at risk (e.g., hospitalized patients) • Observed rate = numerator … ulcer in any secondary diagnosis field among cases meeting the inclusion and exclusion rules for the … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02) http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)� How can the AHRQ PDIs be used in�quality assessment?

429. Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. | PSNet
     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?

430. Psn-Pdf (pdf file)
     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.

431. The effects of harm events on 30-day readmission in surgical patients. | PSNet
     psnet.ahrq.gov/issue/effects-harm-events-30-day-readmission-surgical-patients
     July 31, 2019 - The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%) … March 12, 2014 Detection and prevention of medication misadventures in general practice … Patient and family engagement in catheter-associated urinary tract infection (CAUTI) prevention

432. No More CAUTI: Preventing Catheter-Associated Urinary Tract Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-preventing-cauti-transcript.html
     November 01, 2015 - Finally, Liz served as a national mentor to 2 fellows in the project protect infection prevention fellowship … Today, we're going to be talking specifically about the education component in your CAUDI prevention … For a lot of people, part of their CAUDI prevention program is not only looking at appropriate indication … Again, this is a good visual of we're not talking about just a little stage 1 or stage 2 pressure ulcer … The catheter itself can actually cause pressure ulcers just as much as incontinence can.

433. No More CAUTI: Preventing Catheter-Associated Urinary Tract Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-transcript.html
     December 01, 2017 - Finally, Liz served as a national mentor to 2 fellows in the project protect infection prevention fellowship … Today, we're going to be talking specifically about the education component in your CAUDI prevention … For a lot of people, part of their CAUDI prevention program is not only looking at appropriate indication … Again, this is a good visual of we're not talking about just a little stage 1 or stage 2 pressure ulcer … The catheter itself can actually cause pressure ulcers just as much as incontinence can.

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866261/psn-pdf
     July 10, 2024 - The Prevention of Positioning Injuries during Gynecologic Operations. … Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk … Prevention of well-leg compartment syndrome following lengthy medical operations in the lithotomy position … Well leg compartment syndrome: pathophysiology, prevention, and treatment.

435. Adverse Events. | PSNet
     psnet.ahrq.gov/issue/adverse-events
     October 28, 2020 - June 29, 2016 National Action Plan for Adverse Drug Event Prevention. … Quality and Safety Professionals Patients Medication Errors/Preventable Adverse Drug Events Pressure … Ulcers Surgical Complications View More

436. Facts and Figures 2005
     hcup-us.ahrq.gov/reports/factsandfigures/facts_figures_2005.jsp
     January 01, 2005 - During the 12 year period since 1993, there was a 76 percent increase in pressure sore hospitalizations … sore ICD-9-CM codes: 707.0         Decubitus ulcer 707.00       Decubitus ulcer, unspecified site … 707.01       Decubitus ulcer, elbow 707.02       Decubitus ulcer, upper back 707.03       Decubitus … ulcer, lower back 707.04       Decubitus ulcer, hip 707.05       Decubitus ulcer, buttock 707.06 …        Decubitus ulcer, ankle 707.07       Decubitus ulcer, heel 707.09       Decubitus ulcer, other

437. Inpatient fall prevention programs as a patient safety strategy: a systematic review. | PSNet
     psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
     May 26, 2016 - Review Inpatient fall prevention programs as a patient safety strategy: a systematic … Inpatient fall prevention programs as a patient safety strategy: a systematic review. … An institutional approach to fall prevention is discussed in an AHRQ WebM&M perspective . … Inpatient fall prevention programs as a patient safety strategy: a systematic review. … October 5, 2015 Preventing in-facility pressure ulcers as a patient safety strategy:

438. Disposition of Comments Report for Chronic Venous Ulcers: A Comparative Effectiveness Review of Treatment Modalities (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/venous-ulcers-treatment_disposition-comments.pdf
     January 27, 2014 - We would suggest this be reconsidered, especially in light of the role of biofilms in the prevention

439. The relationship between registered nurses and nursing home quality: an integrative review (2008–2014). | PSNet
     psnet.ahrq.gov/issue/relationship-between-registered-nurses-and-nursing-home-quality-integrative-review-2008-2014
     June 03, 2020 - RN) in a nursing home could affect various quality and safety indicators (such as safety culture , pressure … ulcers, and falls). … Assessing the effectiveness of engaging patients and their families in the three-step fall prevention … process across modalities of an evidence-based fall prevention toolkit: an implementation science study

440. AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016. | PSNet
     psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary
     October 23, 2019 - HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention … While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity