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21. Tool 3F: Orthostatic Vital Sign Measurement | Agency for Healthcare Research and Quality
    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.

22. Weight Summary (doc file)
    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).

23. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
    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.

24. Puh-Assessment (doc file)
    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

25. Puh-Assessment (pdf file)
    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

26. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Slide Presentation | Agency for Healthcare Research and Quality
    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

27. Comparative Effectiveness Reviews | Agency for Healthcare Research and Quality
    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

28. AHRQ Tools To Reduce Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    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

29. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Training Guide | Agency for Healthcare Research and Quality
    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.

30. PowerPoint Presentation
    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

31. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
    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.

32. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
    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.

33. Health Care Facility Design Safety Risk Assessment Toolkit | Agency for Healthcare Research and Quality
    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

34. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
    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.

35. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
    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

36. Results | Agency for Healthcare Research and Quality
    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.

37. Pressure Ulcer Dashboard | Agency for Healthcare Research and Quality
    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

38. Puh-Electronic-Reports (pdf file)
    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

39. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    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.

40. On-Time Preventable Hospital and ED Visits Functional Specs (pdf file)
    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