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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apb.html
October 01, 2017 - Pressure Injury Prevention Program Implementation Guide
Appendix B. … Opportunities for Improvement
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Table of Contents
Pressure Injury … Prevention Program Implementation Guide
Overview
Get Ready
Pressure Injury Prevention Program … Firm up your Implementation Team Leader, Core Team, Pressure Injury Team, and pressure injury champions … They might include ideas such as universal pressure injury precautions, pressure injury risk screening
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhosp-reports-slides.pptx
November 30, 2013 - Major injury
Minor injury
Non-Fall-Related Injury
Major injury
Minor injury
Musculoskeletal
Joint pain … & Skin
Cellulitis
Edema
Infected wound or decubitus
Jaundice
Rash
Treatment Unavailable at Transferring … & Skin Injury: Fall Related Injury : Non-Fall Related Musculoskeletal Abnormal Labs or Anemia Fever/ … or Skin Fall-Related Injury Non-Fall-Related Injury Abnormal Lab Results Fever /
Possible Infection … Disease Asthma Circulatory Problems Hypertension or Renal Failure Gastroenteritis Angina Pectoris Falls /Trauma
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www.ahrq.gov/patient-safety/research-summaries/index.html
August 01, 2025 - facilities (e.g., units, rooms, equipment, logistics, and technologies) can improve patient outcomes, reduce injuries
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiic.html
June 01, 2010 - elders; Adults and/or children with severe and persistent mental illness; Adults with acquired brain injuries … elders; Adults and/or children with severe and persistent mental illness; Adults with acquired brain injuries … elders; Adults and/or children with severe and persistent mental illness; Adults with acquired brain injuries … elders; Adults and/or children with severe and persistent mental illness; Adults with acquired brain injuries … elders; Adults and/or children with severe and persistent mental illness; Adults with acquired brain injuries
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/packet.html
November 01, 2017 - Yes/no
N
N
Y
Y
Y
N
If yes, what type of injury?
… Injury Type: Major
Fracture: hip
X
Fracture: other
…
Joint dislocation
Closed head injury with altered … consciousness
Subdural hematoma
Injury … that causes pain
Injury Site
Head
Upper extremity (UE)
Lower
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2024.xlsx
January 01, 2024 - Documented within 24 hours of admission 0.9% 35
Stage/Category IV Unknown * *
Suspected Deep Tissue Injury … Documented within 24 hours of admission 71.0% 2,897
Suspected Deep Tissue Injury No risk assessment … documented * *
Suspected Deep Tissue Injury Not on admission, but documented after discovery or advancement … of pressure ulcer 78.6% 11
Suspected Deep Tissue Injury Not on admission, but documented before discovery … or advancement of pressure ulcer * *
Suspected Deep Tissue Injury Unknown 69.4% 1,111
Unstageable
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www.ahrq.gov/patient-safety/settings/hospital/resource/transform.html
December 01, 2017 - Patient Falls
Patient falls, which are common in hospitals, can result in serious injuries, extend … By 2020 the estimated annual cost of fall injuries for older people will exceed $30 billion. 7-8 Now … improving light sources for surgical staff; and designing patient beds to reduce back stress, fatigue, and injuries
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Prevention
AHRQ’s Safety Program for Nursing Homes: On-Time Prevention is designed to improve long-term care by turning daily documentation into useful information that enhances clinical care planning.
AHRQ's Safety Program for Nursing Homes: On-Time Prevention…
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www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
April 01, 2021 - of skin at risk for developing pressure ulcers (recently renamed by expert organizations as pressure injury … The M-Safety Lab created a patient safety display—a digital bedside display of catheter and wound information … improved provider's awareness of indwelling urinary catheters, central venous catheters, and pressure injuries
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Rivard.pdf
May 01, 2004 - , delirium
and other psychoses, or anoxic brain injury; or with any
diagnosis of metastatic cancer, … lymphoid malignancy, bone
malignancy or self-inflicted injury. … Postoperative
wound
dehiscence
Discharges with ICD-
9-CM codes for
reclosure of
postoperative … hemorrhage or hematoma, postoperative pulmonary embolism or deep vein
thrombosis, and postoperative wound … Definitions of medical injuries. [See
Comment.] JAMA 2004;291(3):304.
39.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
January 01, 2022 - or complications of pressure injuries present on admission (POA)
was significantly higher (8.4% vs. … of pressure injuries POA was significantly higher for males than
females (7.2% vs. 4.9%). … seizures,
coma)
Death during or shortly after anesthesia in ASA Class 1
patient
Dehiscence, flap or wound … or cranial nerve or spinal cord;
Malignant hyperthermia
Ocular injury
Peri-operative injury
Post-dural … Birth – Neonatal Other birth injury
3.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
January 01, 2022 - or complications of pressure injuries present on admission (POA)
was significantly higher (8.4% vs. … of pressure injuries POA was significantly higher for males than
females (7.2% vs. 4.9%). … seizures,
coma)
Death during or shortly after anesthesia in ASA Class 1
patient
Dehiscence, flap or wound … or cranial nerve or spinal cord;
Malignant hyperthermia
Ocular injury
Peri-operative injury
Post-dural … Birth – Neonatal Other birth injury
3.
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www.ahrq.gov/cahps/surveys-guidance/item-sets/mobility/index.html
February 01, 2021 - conditions including arthritis, heart or lung problems, unmanaged diabetes or obesity, spinal cord injuries
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www.ahrq.gov/topics/ruralinner-city-residents.html
Rural residents also have a higher proportion of injury-related deaths, including drug overdoses, vehicular
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www.ahrq.gov/prevention/resources/vision/resources/vision1.html
October 01, 2002 - for information on rehabilitation for certain of the most studied diseases, including traumatic brain injury … Aside from the few types of more common and medically-oriented rehabilitation (such as for stroke and trauma … We examined the evidence for the effectiveness of rehabilitation for traumatic brain injury, stroke, … University on rehabilitation for traumatic brain injury in adults. 11 (Select for Summary .) … In addition, a number of other diseases, such as stroke, head injury, or tumors may result in conditions
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www.ahrq.gov/hai/cauti-tools/phys-championsgd/section4.html
October 01, 2015 - Acute urinary retention may be medication induced, medical (neurogenic bladder), or related to trauma … Assistance with healing of perineal and sacral wounds in incontinent patients. … Required immobilization for trauma or surgery. … Examples include an unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures … Common indications include respiratory failure, cardiac or pulmonary arrest, laryngeal trauma or edema
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
May 01, 2014 - New or increasing pus draining from wound
Y N ? New breakdown
Y N ? … New or expanding redness around wound
Y N ? Pain / tenderness
Y N ? Warmth
Y N ? … Suspected minor injury Yes No ?
Suspected serious injury Yes No ?
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/leadership-4.html
June 01, 2021 - testing and treatment. 27 This overutilization contributes to harm, with aggressive testing mistakes and injuries
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-new-sops-workplace-safety-mcgaffigan.pdf
December 01, 2020 - www.ihi.org/Engage/Initiatives/Lucian-Leape-Institute/Pages/Publications.aspx
Higher incidence
of injuries
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apiiib.html
June 01, 2010 - Quality of Life
Populations: Elders and adults with physical disabilities, including spinal cord injuries … and acquired brain injuries
Developer: Cheryl Cott, PhD and colleagues, University of Toronto
Use … Malec, PhD, ABPP, The Center for Outcome Measurement in Brain Injury
Use history: In 2005 Kentucky … Consumers were given the inventory when they initially entered the waiver for persons with brain injuries … developed to assist in the clinical evaluation of people during the period following the acquired brain injury