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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - deaths due to health care-associated venous
thromboembolism, sepsis, or patient falls; in-hospital pressure … ulcers; and ventilator-associated pneumonia
incidents.
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psnet.ahrq.gov/primers-0
March 15, 2025 - Complications
(10)
Nosocomial Infections
(6)
Patient Falls
(3)
Pressure … Ulcers
(1)
Medication Safety
(12)
Medication Errors/Preventable Adverse
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psnet.ahrq.gov/topics-0
March 03, 2025 - Nosocomial Infections Go to this topic
Patient Falls Go to this topic
Pressure … Ulcers Go to this topic
Venous Thrombosis and Thromboembolism Go to this topic
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - 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/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - We also experienced, as Rhonda mentioned, difficulties with pressure ulcer prevention and timely response
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - We also experienced, as Rhonda mentioned, difficulties with pressure ulcer prevention and timely response
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
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
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - They're getting decubitus ulcers.
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected
Citation Text:
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/node/841567/psn-pdf
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.
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common?
Mark L. Graber, MD | February 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpi…
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - In Conversation with...Joseph Britto, MD
February 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007.In Conversation with...Joseph Britto, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
March 15, 2023
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of
Gastric Perforation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - They're getting decubitus ulcers.
-
psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - Excludes patients with any diagnosis
code for drug dependence, abuse of drugs, or self-inflicted
injury
Decubitus … ulcer
Pressure sores in patients
hospitalized for 4 days or
longer
Discharges with ICD-9-CM code
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - Delirium
(6)
Nosocomial Infections
(16)
Patient Falls
(8)
Pressure … Ulcers
(1)
Venous Thrombosis and Thromboembolism
(10)
Medication Safety
-
psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - oximetry monitoring, wound care, blood draws, intravenous catheter placement, skin care and prevention of pressure … ulcers, respiratory and ventilator support, and correct administration of medications can all be challenging
-
psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - oximetry monitoring, wound care, blood draws, intravenous catheter placement,
skin care and prevention of pressure … ulcers, respiratory and ventilator support, and correct administration of
medications can all be challenging