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21. In Conversation with...Diane Rydrych, MA | PSNet
    psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
    April 30, 2024 - In certain categories, particularly with something like pressure ulcers, there is almost certainly underreporting … Are pressure ulcers not being discovered, or are they not being correctly staged so that people know … is part of the issue, a better hospital might be more assiduous about finding things like pressure ulcers … One was a facility that had a high number of pressure ulcers. … As a result of that really concerted effort to identify pressure ulcers, they have identified many ulcers

22. Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls. | PSNet
    psnet.ahrq.gov/issue/single-room-hospital-accommodation-associated-differences-healthcare-associated-infection
    October 21, 2015 - hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers … hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers … Falls , pressure ulcers, and Clostridium difficile infections increased in the older patients' ward … hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers … December 21, 2022 Barriers and facilitators to reporting medical device-related pressure ulcers

23. Early identification and evaluation of severe pressure injuries. | PSNet
    psnet.ahrq.gov/issue/early-identification-and-evaluation-severe-pressure-injuries
    October 10, 2018 - recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure ulcers … September 14, 2022 Accuracy of pressure ulcer events in US nursing home ratings. … See More About The Topic Hospitals Long-Term Care Geriatrics Nurse Care Pressure Ulcers

24. The impact of the use of employee functional flexibility on patient safety. | PSNet
    psnet.ahrq.gov/issue/impact-use-employee-functional-flexibility-patient-safety
    February 12, 2020 - effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers … indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers … December 21, 2022 Barriers and facilitators to reporting medical device-related pressure ulcers … October 5, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

25. A multi-disciplinary approach to medication safety and the implication for nursing education and practice. | PSNet
    psnet.ahrq.gov/issue/multi-disciplinary-approach-medication-safety-and-implication-nursing-education-and-practice
    September 26, 2018 - August 19, 2020 Success in hospital-acquired pressure ulcer prevention: a tale in two … February 8, 2017 Organisational strategies to implement hospital pressure ulcer prevention

26. In Conversation with…Robert M. Wachter, MD | PSNet
    psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
    October 01, 2008 - know with good scientific evidence that if you do these five things you will prevent most decubitus ulcers … infarct, stroke, and pulmonary embolism (kappa>0.8) than on the timing of renal failure, decubitus ulcer … in addition to stage 3 or 4 ulcers acquired after admission. … However, only 25% of the last 16 reported patients had an ICD-9-CM secondary diagnosis code of a pressure ulcer … Our administrative system has a limitation of 15 diagnoses, and it is possible that the decubitus ulcer

27. An Easily Forgotten Tube | PSNet
    psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - inpatient stay was prolonged, and he received both transfusion and the colonoscopy because of the rectal ulcer … While the case provides no evidence that the rectal ulcer could have been discovered prior to the initiation

28. Pressure Injury Prevention in Hospitals Training Program. | PSNet
    psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
    November 19, 2014 - Pressure ulcers are a common hospital-acquired condition that can lead to patient harm . … to help hospitals implement practice and process improvements to reduce the occurrence of pressure ulcers … See More About The Topic Hospitals Health Care Providers Medicine Pressure Ulcers

29. Understanding safety culture in long-term care: a case study. | PSNet
    psnet.ahrq.gov/issue/understanding-safety-culture-long-term-care-case-study
    July 01, 2009 - June 3, 2015 Organisational strategies to implement hospital pressure ulcer prevention … August 31, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

30. Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare. | PSNet
    psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
    August 24, 2022 - Citation Related Resources From the Same Author(s) Accuracy of pressure ulcer … August 31, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

31. Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. | PSNet
    psnet.ahrq.gov/issue/implementing-electronic-root-cause-analysis-reporting-system-decrease-hospital-acquired
    December 22, 2021 - December 21, 2022 Barriers and facilitators to reporting medical device-related pressure ulcers … October 12, 2022 Accuracy of pressure ulcer events in US nursing home ratings. … More About The Topic Hospitals Quality and Safety Professionals Nurse Care Pressure Ulcers

32. A model of chemotherapy education for novice oncology nurses that supports a culture of safety. | PSNet
    psnet.ahrq.gov/issue/model-chemotherapy-education-novice-oncology-nurses-supports-culture-safety
    June 28, 2006 - November 30, 2016 Organisational strategies to implement hospital pressure ulcer prevention

33. Medicines related problems (MRPs) originating in primary care settings in older adults - a systematic review. | PSNet
    psnet.ahrq.gov/issue/medicines-related-problems-mrps-originating-primary-care-settings-older-adults-systematic
    March 04, 2015 - September 14, 2022 Accuracy of pressure ulcer events in US nursing home ratings. … Office Primary Care Geriatrics Medication Errors/Preventable Adverse Drug Events Pressure Ulcers

34. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet
    psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
    October 01, 2008 - infarct, stroke, and pulmonary embolism (kappa>0.8) than on the timing of renal failure, decubitus ulcer … in addition to stage 3 or 4 ulcers acquired after admission. … However, only 25% of the last 16 reported patients had an ICD-9-CM secondary diagnosis code of a pressure ulcer … Our administrative system has a limitation of 15 diagnoses, and it is possible that the decubitus ulcer … know with good scientific evidence that if you do these five things you will prevent most decubitus ulcers

35. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet
    psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
    April 01, 2018 - this patient’s case. 8 In the initial stages, syphilis infection manifests as a painless, solitary ulcer … This ulcer is often on the distal penis, but can also occur on the vagina or cervix, the anus, the mouth … Untreated syphilis increases the risk of HIV infection while ulcers are present as syphilitic ulcers

36. Why don't doctors wash their hands more? | PSNet
    psnet.ahrq.gov/issue/why-dont-doctors-wash-their-hands-more
    February 10, 2010 - September 21, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

37. When patient handoffs go terribly wrong. | PSNet
    psnet.ahrq.gov/issue/when-patient-handoffs-go-terribly-wrong
    February 10, 2010 - September 21, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

38. When doctors make mistakes. | PSNet
    psnet.ahrq.gov/issue/when-doctors-make-mistakes-1
    February 10, 2010 - September 21, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

39. Are patients in part to blame when doctors miss the diagnosis? | PSNet
    psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis
    February 10, 2010 - September 21, 2022 Accuracy of pressure ulcer events in US nursing home ratings.

40. Do you know what your doctor is talking about? | PSNet
    psnet.ahrq.gov/issue/do-you-know-what-your-doctor-talking-about
    February 10, 2010 - September 21, 2022 Accuracy of pressure ulcer events in US nursing home ratings.