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teamstepps.ahrq.gov/talkingquality/translate/labels/describe.html
January 01, 2023 - Massachusetts General Hospital (MGH) URL: https://www.massgeneral.org/quality-and-safety/patient-safety/pressure-injury-prevalence … (To view complete information, go to https://www.massgeneral.org/quality-and-safety/patient-safety/pressure-injury-prevalence … Overall, the rate of patients who have pressure ulcers at MGH is low. … that nurses have the necessary knowledge for skin assessment and intervention they attend a Phase I Wound … Bed surface is a key factor in preventing pressure ulcers.
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teamstepps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/webinars/index.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 … Assessment Tools in Care Planning (25 min) ( PDF of the Slides , 2.16 MB)
Measuring Fall and Fall-Related Injury … Network Webinars
Creating Control Charts To Interpret Fall Data (62 min)
Critical Thinking for Fall Injury … Prevention Care Planning (61 min)
Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries
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teamstepps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/index.html
September 01, 2018 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Module 3 Tools ( MS Word , 268 KB)
Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … Network Webinars
Related AHRQ Resources
Preventing Falls in Hospitals Toolkit
Pressure … Injury Prevention in Hospitals Training Program
Page last reviewed September
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
July 01, 2016 - Patient Safety PSI 03 Pressure Ulcer
PSI 06 Iatrogenic Pneumothorax
PSI 07 Central Venous Catheter-Related … Perioperative Pulmonary Embolism or Deep Vein Thrombosis
PSI 13 Postoperative Sepsis
PSI 14 Postoperative Wound … Dehiscence
PSI 15 Accidental Puncture or Laceration
Obstetric PSI 17 Birth Trauma-Injury to Neonate …
PSI 18 Obstetric Trauma-Vaginal Delivery With Instrument
PSI 19 Obstetric Trauma-Vaginal Delivery … 09 Postoperative Respiratory Failure Rate
PDI 10 Postoperative Sepsis Rate
PDI 11 Postoperative Wound
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teamstepps.ahrq.gov/research/findings/studies/index.html?page=1
January 01, 2024 - and Wounds
(207)
Inpatient Care
(220)
Intensive Care Unit (ICU)
(264)
Kidney Disease and … Outcome measures included hypertension, systolic blood pressure >130 mmHG, and hyperglycemia. … center (NTC) and were diagnosed with a traumatic injury with an injury severity score of greater than … , major chest injury, and presentation at a teaching hospital. … , Injuries and Wounds
Cron DC , Braun HJ , Ascher NL Sex-based disparities in access to
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 05, 2016 - Best practices forms exist for the following 14 PSIs:
• PSI 03 Pressure Ulcer Rate
• PSI 05 Retained … Pulmonary Embolism or Deep Vein Thrombosis Rate
• PSI 13 Postoperative Sepsis Rate
• PSI 14 Postoperative Wound … 03 Neonatal Blood Stream Infection Rate
• PDI 01 Accidental Puncture or Laceration Rate
• PDI 02 Pressure … Postoperative Respiratory Failure Rate
• PDI 10 Postoperative Sepsis Rate
• PDI 11 Postoperative Wound … • PSI 17 Birth Trauma Rate―Injury to Neonate: The existing literature on birth trauma
and injury
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teamstepps.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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teamstepps.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - Falls Management Program
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Provider Fax Report and Orders
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … professionals/onthejob/falls.asp
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/index.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx … /fallspx/fallspxmanapb10pcp.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries
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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.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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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
March 15, 2016 - PDI 02 Pressure Ulcer Rate (stage
III, IV, Unstageable)
Diagnosis and site of pressure ulcer must … PSI 18,
PSI 19
OB Trauma – Vaginal Delivery
With Instrument
OB Trauma – Vaginal Delivery
Without … X
PDI 11 Postoperative Wound
Dehiscence Rate
X Depth of the wound dehiscence:
external/superficial … X
PSI 14 Postoperative Wound
Dehiscence
X Depth of the wound dehiscence:
external/superficial vs … PSI 18
PSI 19
OB Trauma – Vaginal
Delivery With Instrument
OB Trauma – Vaginal
Delivery Without
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teamstepps.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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teamstepps.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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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
July 01, 2016 - Patient Safety PSI 03 Pressure Ulcer 1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y
PSI 06 Iatrogenic … 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y
PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y
Obstetric PSI 17 Birth Trauma-Injury … to Neonate 0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y
PSI 18 Obstetric Trauma-Vaginal Delivery … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y
PDI 11 Postoperative Wound
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teamstepps.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
November 01, 2021 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Nursing Homes: On-Time Prevention
End of Life Care
Home and Community-based Services
Falls and Injury … Long-Term Care Facilities
Multiple Chronic Conditions
Omissions of Care in Nursing Homes
Pressure
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teamstepps.ahrq.gov/patient-safety/settings/long-term-care/index.html
September 01, 2021 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to … help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.
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teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system
depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate
poisoning, … expansion exercises with
children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory
failure in children: a concise review
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teamstepps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-1/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 … Between 30 and 51 percent of falls in hospitals result in an injury ranging from bruises to severe wounds … The cost of serious fall-related injuries at three Midwestern hospitals. … Thus, the CAUTI, SSI, and Pressure Injury committees used the AHRQ assessment tools, and a speak-up campaign