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Search results for "Pressure Ulcers"
- Discontinuities, Gaps, and Hand-Off Problems
- Pressure Ulcers
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Amy A. Vogelsmeier, PhD, RN; September 2011
Following surgical repair for a hip fracture, a nursing home resident with limited mobility developed a fever. She was readmitted to the hospital, where examination revealed a very deep pressure ulcer. Despite maximal efforts, the patient developed septic shock and died.
Journal Article > Study
Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.
This study reports on Kaiser Permanente's use of systems analysis approaches to review all cases of inpatient mortality, with the goal of identifying preventable harm.