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psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm
June 01, 2016 - January 23, 2019
Success in hospital-acquired pressure ulcer prevention: a tale in two
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - An Easily Forgotten Tube
Citation Text:
Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - made in the past 10 years—improvements in healthcare-acquired infections, decreases in patient falls,
pressure … ulcers, and other complications. … Falls and pressure ulcers also went up – in skilled
nursing facilities, we saw rates of falls causing … major injury increase by 17% and pressure ulcers increase
by over 40%.
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - systematically addresses most
likely areas of risk (e.g., central line infection, urinary infection, delirium, pressure … ulcers), and (iv)
using the daily goal sheet to promote ongoing open dialogue.
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psnet.ahrq.gov/node/33676/psn-pdf
November 01, 2008 - On the one hand, we're trying to get patients up out of bed to prevent deconditioning, decubitus
ulcers … , and pressure sores, but the urinary catheter is tethering them to the bed, preventing them from
getting
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psnet.ahrq.gov/node/851555/psn-pdf
July 31, 2023 - Bandemia as a Harbinger of Stercoral Colitis and
Impending Perforation
July 31, 2023
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
The Case
A 56-year-…
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - made in the past 10 years—improvements in healthcare-acquired infections, decreases in patient falls, pressure … ulcers, and other complications. … Falls and pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing … major injury increase by 17% and pressure ulcers increase by over 40%. … ulcers. 14 Healthcare leaders recognize the need to do better.
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - increased with a 40% rise in healthcare-acquired infections and an increase in inpatient falls and pressure … ulcers. 14 Healthcare leaders recognize the need to do better. … ulcers, and other complications. … Falls and pressure ulcers also went up – in skilled nursing facilities, we saw rates of falls causing … major injury increase by 17% and pressure ulcers increase by over 40%.
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psnet.ahrq.gov/node/61082/psn-pdf
July 23, 2020 - individuals can gain from social interaction and enhanced mobility, such as reduced risk of falls and
pressure … ulcers. … mitigate safety risks associated with usual care
needs for this patient population, such as falls and pressure … ulcers.
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - systematically addresses most likely areas of risk (e.g., central line infection, urinary infection, delirium, pressure … ulcers), and (iv) using the daily goal sheet to promote ongoing open dialogue.
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - Prolonged hospital bedrest leads to loss of muscle and bone mass and increases the risk of pressure ulcers … Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam Dressings.
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psnet.ahrq.gov/issue/evaluation-association-between-nursing-home-survey-patient-safety-culture-nhsops-measures-and
April 05, 2017 - December 21, 2017
Success in hospital-acquired pressure ulcer prevention: a tale in two
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - These
require SNFs to have measures in place to prevent specific clinical harms (such as falls, pressure … ulcers,
and health care–associated infections) and to improve medication management.
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure … ulcers.
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psnet.ahrq.gov/node/865296/psn-pdf
March 27, 2024 - facilitating clinician communication, as well as preventing hospital-associated infections, falls, pressure … ulcers, and inpatient suicide.
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - They're getting decubitus ulcers.
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - contribute to delirium, hypotension, falls, and immobility along with its complications, such as pressure … ulcers and, as may have occurred in this case, aspiration pneumonia.
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Delirium
(4)
Nosocomial Infections
(3)
Patient Falls
(5)
Pressure … Ulcers
(1)
Venous Thrombosis and Thromboembolism
(3)
Medication Safety