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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citati…
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - We also experienced, as
Rhonda mentioned, difficulties with pressure ulcer prevention and timely response
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - 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/web-mm/snfs-opening-black-box
August 27, 2012 - can 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/curated-article-libraries
March 18, 2025 - Complications
(4)
Nosocomial Infections
(4)
Patient Falls
(1)
Pressure … Ulcers
(1)
Medication Safety
(6)
Medication Errors/Preventable Adverse
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
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 … States, we have since experienced higher rates of preventable infections, as well as increases in pressure … ulcers and falls.
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - States, we have since experienced higher rates of preventable infections, as well as increases in pressure … ulcers and falls. … 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
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psnet.ahrq.gov/node/33872/psn-pdf
January 01, 2018 - While this
intervention did not reduce safety incidents like pressure ulcers or falls, it did identify
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - and malnutrition
Aspiration pneumonia
Nosocomial infection (especially due to urinary catheters)
Pressure … ulcers
See Notes for reference.
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - because they are able to do the basics
every time, like turning patients every 60 minutes to avoid pressure … ulcers, using a central line checklist, or
washing their hands frequently.
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psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers
Citation Text:
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - kernicterus) associated with failure to identify and treat
hyperbilirubinemia in neonates
Stage 3 or 4 pressure … ulcers acquired after admission to a health care facility
Patient death or serious disability due to
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psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - is that there are four risk factors that underlie many of our hospital acquired
conditions, (i.e., pressure … ulcers and catheter associated infections, falls, and delirium).
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psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Although differences have been
reported on patient variables like hospital-acquired pressure ulcers,
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - experience, and
prevention of patient safety events and adverse events such as medication issues, falls, pressure … ulcers,
and infections.
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - facilitating clinician communication, as well as preventing hospital-associated infections, falls, pressure … ulcers, and inpatient suicide.
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psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - While this intervention did not reduce safety incidents like pressure ulcers or falls , it did identify
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - SPOTLIGHT CASE
Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation
Citation Text:
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - deaths due to health care-associated venous thromboembolism, sepsis, or patient falls; in-hospital pressure … ulcers; and ventilator-associated pneumonia incidents.