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721. 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

722. Improving Safety Using Teamwork and Patient Safety Norms (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
     August 01, 2025 - Skin: Pressure Ulcer? POA? - Current descript ion of PU 10. Foley: Can it be removed? … in ICUs and non-ICUs https://www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/index.html 46 https: … //www.ahrq.gov/hai/tools/mrsa-prevention/toolkit/index.html In Progress: AHRQ Safety Program for Telemedicine … index.html https://www.ahrq.gov/antibiotic-use/index.html Now Enrolling: AHRQ Safety Program for HAI Prevention … Safety Program for Telemedicine: Improving Antibiotic Use Now Enrolling: AHRQ Safety Program for HAI Prevention

723. Factor structure and construct validity of a hospital survey on patient safety culture using exploratory factor analysis. | PSNet
     psnet.ahrq.gov/issue/factor-structure-and-construct-validity-hospital-survey-patient-safety-culture-using
     June 29, 2022 - June 29, 2022 Evaluation of clinical practice guidelines on fall prevention and management … medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention … February 22, 2023 Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.

724. 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

725. Antiseptic-impregnated catheters: Is the Juice Worth the Squeeze?
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-plan-b-110414.pptx
     January 01, 2013 - Learning Objectives Define basic principles of CAUTI prevention Describe approaches to consider if CAUTI … them to be State how the GPS can support units with ongoing CAUTI problems Apply mindfulness to CAUTI prevention … Fakih) Urinary Catheter Harm CAUTI Increased Length of Stay Patient discomfort Trauma Pressure … ulcers Immobility How can we reduce catheter use and prevent CAUTI? … practices on their units Examples Doctors have no idea what the nurses do with respect to CAUTI prevention

726. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     datatools.ahrq.gov/action-alliance/wp-content/uploads/sites/8/2025/09/qsrs-2021-2023-adverse-event-data-report.pdf
     January 01, 2025 - https://www.ahrq.gov/patient-safety/settings/index.html 2 Centers for Disease Control and Prevention … xx Office of Disease Prevention and Health Promotion, "National Action Plan for Adverse Drug Event Prevention

727. 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

728. Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Savitz.pdf
     March 01, 2004 - represent an evolution of AHRQ’s interest in quality of care and consist of three indicator sets: prevention … ulcers, and mortality, with increasing detail in measure specification.11 For example, nosocomial … accepted n=7) Provisional NQF (n=13) ANA (n=10) Death in low mortality DRG X Decubitus/pressure … ulcer X X X Failure to rescue X X X Infection due to medical care X • Urinary tract infection … We see virtually no direct overlap in these measure sets, with the exception of decubitus/pressure ulcer

729. Final Progress Report: Effects of Patient Turnover on Nursing Care and Patient Outcomes in Acute Care Hospital Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/park-report.pdf
     January 01, 2024 - example, by failing to provide the remaining patients with adequate nursing care required for fall prevention … and pressure injury (formerly known as ulcers) prevention and treatment due to lack of time or increased … NDNQI Unit-acquired pressure injury Unit Number of patients who acquired a pressure ulcer after arrival … to the unit/total number of patients assessed in the pressure ulcer survey.

730. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/painmgmt-facguide.docx
     January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle Slide Title and Commentary Slide Number and Slide … “A” represents the assessment, prevention, and management of pain. … with safety through protocolization, the ABCDEF bundle, and delirium monitoring and management for the prevention … of such errors as hospital-acquired infections, falls, deep vein thromboses, pressure ulcers, and medication

731. Human performance breakdowns are rarely accidents: they are usually very poor choices with disastrous results. | PSNet
     psnet.ahrq.gov/issue/human-performance-breakdowns-are-rarely-accidents-they-are-usually-very-poor-choices
     September 12, 2016 - July 10, 2024 Are evidence-based practices associated with effective prevention of hospital-acquired … pressure ulcers in US academic medical centers?

732. Bleeding Risks With Aspirin Use for Primary Prevention in Adults: A Systematic Review for the USPSTF (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/j69Hq5ALvzg74e-ngkzSep
     April 01, 2016 - We stratified results by population (primary prevention of CVD, secondary prevention of CVD, and colorectal … Major GI bleeding in CVD primary prevention trials. … and Diabetes; PPP = Primary Prevention Project; TPT = Thrombosis Prevention Trial; WHS = Women's Health … ratio; PHS = Physicians' Health Study; PPP = Primary Prevention Project; TPT = Thrombosis Prevention … Data are from 8 CVD primary prevention trials.

733. Patient- and family-centered care: error disclosure and investigation. | PSNet
     psnet.ahrq.gov/issue/patient-and-family-centered-care-error-disclosure-and-investigation
     July 15, 2009 - January 18, 2023 Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice. … teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention

734. Aspirin Use in Primary Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-detail-aid.pdf
     April 01, 2016 - Aspirin for primary prevention: balancing risk & benefit • Aspirin as primary prevention reduces total … Centers for Disease Control and Prevention. … Meta-analysis of multiple primary prevention trials of cardiovascular events using aspirin. … Aspirin for secondary prevention: the clear choice Aspirin for primary prevention: balancing risk … & benefit Which patients should take aspirin for primary prevention?

735. Cost-effectiveness of a quality improvement programme to reduce central line–associated bloodstream infections in intensive care units in the USA. | PSNet
     psnet.ahrq.gov/issue/cost-effectiveness-quality-improvement-programme-reduce-central-line-associated-bloodstream
     January 02, 2017 - February 15, 2011 Are evidence-based practices associated with effective prevention of … hospital-acquired pressure ulcers in US academic medical centers? … , and catheter-associated urinary tract infection (CAUTI): the urgent need to refocus on hardwiring prevention

736. Sampleransferandintakenotes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
     June 02, 2025 - Medication reaction  Mental status change  Mental disorder/psychosis  Neoplasm  Pneumonia  Pressure … ulcer  Peripheral vascular disease  Respiratory, other nonpneumonia  Renal disease  Seizure

737. PQMP Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/measures/index.html?page=0
     Measurement (CEPQM) NQF Endorsement Number: 3136 Initial Risk Assessment for Immobility-Related Pressure … Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission Measure Subdomain: Management

738. Good Practice Guides on Medication Errors: Part 1 and Part 2. | PSNet
     psnet.ahrq.gov/issue/good-practice-guides-medication-errors-part-1-and-part-2
     August 03, 2016 - Medication Errors: New Eu Good Practice Guide On Risk Minimisation And Error Prevention. … Medication Errors: New Eu Good Practice Guide On Risk Minimisation And Error Prevention. … June 27, 2018 Prevention Is Better Than Cure: Learning From Adverse Events in Healthcare … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors?

739. Archived: Final Research Plan: Aspirin to Prevent Cardiovascular Disease: Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan-aspirin-to-prevent-cardiovascular-diseas/aspirin-to-prevent-cardiovascular-disease-and-cancer-april-2016
     October 07, 2013 - Included Excluded Aim Primary prevention of cardiovascular disease: MI, stroke, death from … MI or stroke, or all-cause mortality Secondary and tertiary prevention of MI, stroke, death from MI

740. 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.