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581. Fact Sheet on Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
     October 01, 2015 - Each PDI in the composite is amenable to prevention through system-level related structures and processes … Infection Rate 25.18 0478 2013 PDI 01 Accidental Puncture or Laceration Rate 0.46 0344 2012 PDI 02 Pressure … Ulcer Rate 0.27 0337 2015 PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count N/A*

582. Recommendations to Improve Children's Health Care Quality Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/pubs/background-2012/backgrndapb.html
     December 01, 2012 - illness (CAHMI) 6,3   0081 Pediatric Global Health Scale (CHOP) N/A 7,3.75   Prevention … 4.5,2   0010 Postoperative wound dehiscence (PDI 11) (AHRQ) 6,3 5,3.75   0005 Pressure … ulcer rate (PDI 2) (AHRQ) 7,3 6.5,3.75   0004 Accidental puncture or laceration (PDI 1

583. Resources and Tools on Patient and Healthcare Workforce Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/index.html
     March 01, 2025 - Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure … Ulcers Readmissions Sepsis Surgical Safety Transitions in Care Venous Thromboembolism Interested in

584. Using pharmacogenetics to improve drug safety and efficacy. | PSNet
     psnet.ahrq.gov/issue/using-pharmacogenetics-improve-drug-safety-and-efficacy
     November 18, 2016 - October 6, 2021 Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice. … medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention

585. Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? | PSNet
     psnet.ahrq.gov/issue/rates-adverse-events-hospitalized-patients-after-summer-time-resident-changeover-united
     June 22, 2022 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors? … Hospitals Medicine Medication Errors/Preventable Adverse Drug Events Nosocomial Infections Pressure … Ulcers View More

586. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery | PSNet
     psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
     January 29, 2021 - 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.

587. A culture of civility: positively impacting practice and patient safety. | PSNet
     psnet.ahrq.gov/issue/culture-civility-positively-impacting-practice-and-patient-safety
     July 13, 2022 - July 29, 2015 Are evidence-based practices associated with effective prevention of hospital-acquired … pressure ulcers in US academic medical centers?

588. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46404/psn-pdf
     December 07, 2017 - Adverse events included medication errors and hospital-acquired conditions, such as pressure ulcers

589. In Conversation with...Diane Rydrych, MA | PSNet
     psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
     February 26, 2025 - In certain categories, particularly with something like pressure ulcers, there is almost certainly underreporting … Are pressure ulcers not being discovered, or are they not being correctly staged so that people know … ulcers and other errors. … One was a facility that had a high number of pressure ulcers. … As a result of that really concerted effort to identify pressure ulcers, they have identified many ulcers

590. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39777/psn-pdf
     November 04, 2012 - The most common preventable errors were pressure ulcers—considered a never event—and health care–associated

591. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44388/psn-pdf
     October 14, 2015 - The study looked at four nursing-sensitive adverse outcomes: pressure ulcers, falls with injuries, catheter-associated

592. CMS's hospital-acquired condition lists link hospital payment, patient safety. | PSNet
     psnet.ahrq.gov/issue/cmss-hospital-acquired-condition-lists-link-hospital-payment-patient-safety
     May 20, 2009 - September 29, 2017 Preventing in-facility pressure ulcers as a patient safety strategy … March 20, 2013 Inpatient fall prevention programs as a patient safety strategy: a systematic

593. Engagement of leadership in quality improvement initiatives: executive quality improvement survey results. | PSNet
     psnet.ahrq.gov/issue/engagement-leadership-quality-improvement-initiatives-executive-quality-improvement-survey
     October 04, 2006 - June 8, 2016 Are evidence-based practices associated with effective prevention of hospital-acquired … pressure ulcers in US academic medical centers?

594. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. | PSNet
     psnet.ahrq.gov/issue/improved-outcomes-fewer-cesarean-deliveries-and-reduced-litigation-results-new-paradigm
     November 27, 2012 - September 23, 2020 Universal protection: operationalizing infection prevention guidance … November 14, 2018 A comprehensive program to reduce rates of hospital-acquired pressure … ulcers in a system of community hospitals.

595. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement | PSNet
     psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
     July 01, 2004 - 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. … ulcers, and thromboembolic events. … January 31, 2011 WebM&M Cases An Ounce of Prevention

596. Hospital progress in reducing error: the impact of external interventions. | PSNet
     psnet.ahrq.gov/issue/hospital-progress-reducing-error-impact-external-interventions
     December 04, 2016 - June 8, 2016 Are evidence-based practices associated with effective prevention of hospital-acquired … pressure ulcers in US academic medical centers?

597. Patient safety indicators during the initial COVID-19 pandemic surge in the United States. | PSNet
     psnet.ahrq.gov/issue/patient-safety-indicators-during-initial-covid-19-pandemic-surge-united-states
     August 03, 2022 - Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention … About The Topic Hospitals Public Health Infectious Diseases Medical Complications Pressure … Ulcers View More

598. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47760/psn-pdf
     February 06, 2019 - highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure … ulcer while in the hospital.

599. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49701/psn-pdf
     February 01, 2014 - fully closed system that collects and contains liquid or semi-liquid stools and can assist in the prevention

600. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40841/psn-pdf
     October 16, 2012 - authors arrive at estimates of the daily risk of various safety problems, including adverse drug events, pressure … ulcers, and hospital-acquired infections, and also find that the probability of experiencing an adverse