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psnet.ahrq.gov/issue/make-or-buy-patient-safety-solutions-resource-dependence-and-transaction-cost-economics
April 08, 2008 - December 30, 2014
Preventing in-facility pressure ulcers as a patient safety strategy
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psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety
October 23, 2013 - Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure … ulcers: a systematic review and documentary analysis.
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psnet.ahrq.gov/issue/survey-hospital-quality-improvement-activities
January 27, 2019 - Related Resources
A comprehensive program to reduce rates of hospital-acquired pressure … ulcers in a system of community hospitals.
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psnet.ahrq.gov/issue/safety-and-risk-management-interventions-hospitals-systematic-review-literature
April 01, 2010 - March 3, 2011
Barriers and facilitators to reporting medical device-related pressure … ulcers: a qualitative exploration of international practice.
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psnet.ahrq.gov/issue/can-patient-involvement-improve-patient-safety-cluster-randomised-control-trial-patient
December 21, 2016 - Investigators compared a global measure of safety, which included pressure ulcers , venous thromboembolism
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psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - View More
Related Resources
Organisational strategies to implement hospital pressure … ulcer prevention programmes: findings from a national survey.
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psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize
August 24, 2011 - February 5, 2020
Accuracy of pressure ulcer events in US nursing home ratings.
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - Tracheostomy devices can cause pressure ulcers, particularly along the inferior aspect of the tracheostomy … skin-barrier dressing under the tracheostomy faceplate, can reduce the incidence of tracheostomy-related pressure … ulcers.
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psnet.ahrq.gov/issue/front-line-defense-role-nurses-preventing-sentinel-events-third-edition
November 27, 2018 - December 15, 2017
Organisational strategies to implement hospital pressure ulcer prevention
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psnet.ahrq.gov/node/49644/psn-pdf
December 01, 2011 - Missing the Point—Eye Injury
December 1, 2011
Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/missing-point-eye-injury
The Case
A 31-year-old woman presented to the emergency department (ED) after suffering multiple lacerations
during an assault. The pati…
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Hip fracture and pressure ulcers - the Pan-European Pressure Ulcer Study - intrinsic and extrinsic risk
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psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary-0
October 23, 2019 - highlighted the clinical significance of HACs and described an incident involving a patient who developed a pressure … ulcer while in the hospital.
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - However, the key findings in a recent integrative review include fewer pressure ulcers and urinary tract … included patient-centered outcomes considered to be markers of nursing care quality (such as falls and pressure … ulcers) and system-related measures including nursing skill mix, nursing care hours, measures of the
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psnet.ahrq.gov/issue/us-nursing-homes-where-covid-19-killed-scores-even-reports-maggots-and-rape-dont-dock-five
December 22, 2021 - March 29, 2023
Accuracy of pressure ulcer events in US nursing home ratings.
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - However, the key findings in a recent integrative review
include fewer pressure ulcers and urinary tract … included patient-centered outcomes considered to be markers of nursing care quality (such as falls
and pressure … ulcers) and system-related measures including nursing skill mix, nursing care hours,
measures of the
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psnet.ahrq.gov/issue/one-size-fits-all-mixed-methods-evaluation-impact-100-single-room-accommodation-staff-and
July 01, 2016 - room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors?
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psnet.ahrq.gov/innovation/there-app-mobile-technology-improves-complication-reporting-and-resident-perception
November 28, 2012 - to report major and minor complications (e.g., unplanned re-operation, infection, medication error, pressure … ulcers).
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psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - An Easily Forgotten Tube
February 1, 2014
Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/easily-forgotten-tube
The Case
A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol
abuse. His illness was complicated by acute…
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psnet.ahrq.gov/issue/managing-medication-errors-qualitative-study
December 06, 2023 - December 18, 2017
Organisational strategies to implement hospital pressure ulcer prevention
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - Studies show that an
increase in healthcare-acquired infections, falls, and pressure ulcers has occurred … Similar increases were observed in falls and pressure ulcers at skilled nursing facilities
and preventable