title: Preventing Pressure Ulcers in the Veterans Health Administration Using a Virtual Breakthrough Series Collaborative.
abstract: The Veterans Health Administration implemented a Virtual Breakthrough Series to prevent pressure ulcers. The pressure ulcer rate decreased from 1.2 to 0.9 per 1000 bed days of care (P = .017). The most common interventions were education (N = 26; 68%), improved documentation (N = 23; 61%), and the use of equipment and supplies (N = 21; 55%). In summary, this project helped improve pressure ulcer rates in the Veterans Health Administration and presents a promising model for implementing a virtual model for improvement.
authors.affiliation: VA National Center for Patient Safety, White River Junction, Vermont (Drs Zubkoff, Young-Xu, and Mills and Mss Neily, and Boar); Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Dr Zubkoff); National Center for Patient Safety, Ann Arbor, Michigan (Ms King); and Office of Nursing Services, VA Central Office, Washington, DC (Ms Morgan).
authors.forename: Lisa
authors.initials: L
authors.lastname: Zubkoff
authors.forename: Julia
authors.initials: J
authors.lastname: Neily
authors.forename: Beth
authors.initials: B
authors.lastname: King
authors.forename: Storm
authors.initials: S
authors.lastname: Morgan
authors.forename: Yinong
authors.initials: Y
authors.lastname: Young-Xu
authors.forename: Shoshana
authors.initials: S
authors.lastname: Boar
authors.forename: Peter
authors.initials: P
authors.lastname: Mills
mesh_terms: D004282:Documentation / Q000379:methods; D055318:Evidence-Based Nursing; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D003668:Pressure Ulcer / Q000517:prevention & control*; D058996:Quality Improvement / Q000458:organization & administration; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration*; D058014:Veterans Health