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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html
January 01, 2013 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Have possible spinal injuries.
Have lower extremity or pelvic fractures. … Blood pressure cuff of correct size for the patient. … Check sitting blood pressure and pulse. … Support the forearm at heart level when taking the blood pressures to prevent inaccurate measurement.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
February 10, 2014 - The vendor determines the methodology to assign unique IDs to resident wounds. … :
· 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Most Recent Assess Ulcer Stage … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Ulcer Origin
Wound Assessment … :
Stage 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Ulcer Origin
Wound Assessment … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI).
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/index.html
March 01, 2024 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … pressure ulcer prevention practices through an interdisciplinary approach to care. … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. … injury prevention.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
April 08, 2016 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing
On-Time Pressure Ulcer Assessment … The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool … In partial thickness wounds it can occur throughout the wound bed as well as from the wound edges. … In full thickness wounds it occurs from the edges only. … Stage 3
Stage 4
Unstageable
Suspected Deep Tissue Injury
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
December 15, 2016 - The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment … In partial thickness wounds it can occur throughout the wound bed as well as from the wound
edges. … In full thickness wounds it occurs from the edges only. … to <50% wound covered
5= <25% wound covered
Pain
Pressure Ulcer Site Pain
Select … Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Suspected Deep Tissue Injury
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … None or no injury: The patient is free of injuries (no signs or symptoms) resulting from a fall … Death: The patient died as a result of injuries sustained from the fall (not from physiologic events … Slide 13: NDNQI Definitions of Fall Injury
None: No injury
Minor: Resulted in bruise, abrasion
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preventiveservices.ahrq.gov/patient-safety/settings/long-term-care/resource/reviews.html
August 01, 2018 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Versus Institutional Care
Nonpharmacologic Interventions for Agitation and Aggression in Dementia
Pressure … Ulcer Risk Assessment and Prevention: Comparative Effectiveness
Pressure Ulcer Treatment Strategies
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preventiveservices.ahrq.gov/hai/hac/tools.html
March 01, 2024 - Hospitals
Central line-associated blood stream infections (CLABSI): Tools for Reducing CLABSI
Injuries … Non-ICU Patients With Devices
Obstetrical adverse events: Toolkit for Improving Perinatal Safety
Pressure … ulcers: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care
Surgical
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … injuries (no signs or symptoms) resulting from the fall. … treating with ice, cleaning the wound, limb elevation, topical medication, or a bruise or abrasion. … Interventions to prevent falls and fall injuries are tracked.
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preventiveservices.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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preventiveservices.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
October 01, 2015 - MPSMS (2013) In-Hospital Patient
Falls
240,000 7.2
Obstetric
Adverse
Events
PSI (2013) OB Trauma … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. … Eliminating birth trauma at Ascencion Health.
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preventiveservices.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s)
present … , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh]
OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … Tissue Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ostomy/wound Mgmt. 2016 Nov;62(11):30.
d Weiser TG, Semel ME, Simon AE, et al. … Ostomy Wound Manage. 2016 Nov;62(11):30-8.
65 Mendizabal A, Thibault DP, Willis AW.
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
October 01, 2020 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … The toolkit:
Targets six areas of safety—infections, falls, medication errors, security, injuries of
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s)
present … , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh]
OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … Tissue Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ostomy/wound Mgmt. 2016 Nov;62(11):30.
d Weiser TG, Semel ME, Simon AE, et al. … Ostomy Wound Manage. 2016 Nov;62(11):30-8.
65 Mendizabal A, Thibault DP, Willis AW.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
January 01, 2019 - event type; and, detailed information about specific event types,
such as the distribution of various injuries … pertaining to nine patient safety event
types that represent the majority of reported preventable injuries … Event-Specific Formats pertain to nine patient safety events that represent the great majority of
preventable injuries … that they represent minor injuries such as soreness, bumps, and
minor abrasions. … unstageable
A lesion that, on admission, was a suspected Deep Tissue Injury
A pressure ulcer at stage
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preventiveservices.ahrq.gov/hai/pfp/haccost2017-results.html
November 01, 2017 - literature on excess mortality may be due to the difficulty in finding reliable sources of data on injuries … One study used national representative data (HCUP-NIS) for obstetrical trauma (defined based on AHRQ … only. 54 Further, this study found no increase in mortality for obstetrical trauma. … studies included amniotic fluid embolisms and anesthesia complications; two studies included intracranial injuries … and internal injuries of thorax, abdomen, and pelvis; one study included iatrogenic events.
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preventiveservices.ahrq.gov/npsd/data/dashboard/pressure-ulcer.html
October 01, 2023 - of Patient Safety Databases (NPSD)
Data Reporting Tools
NPSD Dashboards
Pressure … SHARE:
Go to NPSD Dashboards
Pressure … This dashboard details the documentation of increased risk for pressure ulcer following a risk assessment … ; and the timing of the first risk assessment for reported pressure ulcers or sDTIs. … https://www.ahrq.gov/npsd/data/dashboard/pressure-ulcer.html
Back to
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-electronic-reports.pdf
February 10, 2014 - This report is helpful for nursing home staff and
wound nurses to promote early identification of pressure … These details are available at the time the pressure ulcer is being assessed during wound rounds
or … For example,
the Pressure Ulcers At Risk for Delayed Healing Report; Weekly Wound Rounds Report; … DON or ADON, Nurse Manager, Wound Nurse, QI
Director
Root Cause Analysis for New Pressure Ulcers … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury
Alliance
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preventiveservices.ahrq.gov/data/infographics/hac-rates_2019.html
July 01, 2020 - Description: National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Pressure ulcers: 6% increase. Surgical site infections: 8% increase.
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
August 01, 2017 - Ulcer
Vendor determined
or Wound
Assessment
Pressure ulcer Stage II,
III, IV, or unstageable. … IF wound assessment date ≤7 days of
report date AND at least one pressure
ulcer with ulcer stage = … then display X in Wound
• Infected wound or decubitus ulcer
• Jaundice
• Rash
10 Injury: Fall … X in Injury:
11 Injury: Non-
Fall Related
Transfer
Note
•
•
Major injury
Minor injury
IF … Chest pain/angina
Dizzy/lightheaded
Non-Fall-Related Injury
Major injury
Minor injury