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

102. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
     April 01, 2025 - Preventing Falls and Reducing Injury from Falls https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries … Pressure Ulcer Reduction 1. … Pressure Injury Training Modules https://npiap.com/page/TrainingModules The NPIAP Pressure Injury … injuries. 3. … Ulcer Data Collection Tool Instructions Preventing Falls and Reducing Injury from Falls Quality Assurance

103. Session 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess2.html
     October 01, 2014 - Additional Tools and Resources Limiting Falls that Cause Injury Residents in long-term … However, what we can do is eliminate needless falls and limit the injuries from falls that do occur. … Things about the equipment or care plan (e.g., monitor blood pressure frequently). … Things about equipment or the care plan, including: More frequent blood pressure monitoring. … Relationship between physical restraint removal and falls and injuries among nursing home residents.

104. Using Pressure Ulcer Risk Assessment Tools in Care Planning (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar5_pu_riskassesst-tools.pdf
     January 01, 2012 - Adv Skin Wound Care 2001;14(3):133-7. 38 Resources • John A. … Injury Alliance. … Adv Skin Wound Care 2012; 25(4):167-88. • Rapp MP, Bergstrom N, Padhye NC. … Adv Skin Wound Care 2009;22(11):506-13. • Shanks HT, Kleinhelter P, Baker J. … Adv Skin Wound Care 2011;24(12):562-70. 39 http://www.hartfordign.org/practice/try_this/ Using Pressure

105. Staff Roles and Training forYour Pressure Ulcer Prevention Program (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar3_pu_staffroles.pdf
     January 01, 2014 - Program. 8 Wound Care Team: Roles and Duties • Serve as your hospital’s content experts on pressure … ulcer injury prevention … Nursing 2014 survey results: Wound care and prevention. … Advances in Skin and Wound Care. 2010; 23(3):120-31. • Levine J, et al. … Advances in Skin and Wound Care. 2007; 20(1):34-38. 37 Staff Roles and Training forYour Pressure

106. Final Progress Report: Effects of Patient Turnover on Nursing Care and Patient Outcomes in Acute Care Hospital Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/park-report.pdf
     January 01, 2024 - • Hypothesis 4: Higher unit patient turnover will be associated with more pressure injuries and falls … NDNQI Unit-acquired pressure injury Unit Number of patients who acquired a pressure ulcer after arrival … , Poisson regression modeling for falls and injury falls and logistic regression modeling for pressure … falls, and pressure injuries, as reported by NDNQI. … Unit-level patient outcomes of falls, injury falls, and pressure injuries were not statistically significant

107. C1 Prioritization Worksheet (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
     June 02, 2025 - 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

108. Initial Risk Assessment for Immobility-Related Pressuer Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-203-fullreport.pdf
     April 10, 2017 - Ulcer Advisory Panel (EPUAP) — “A pressure ulcer is localized injury to the skin and/or underlying … ulcers are a serious iatrogenic injury. … They may have preexisting wounds or altered skin integrity due to a variety of factors related to their … Are pressure ulcers preventable? A survey of experts. Adv Skin Wound Care 2001; 14(5):244-8. … Unavoidable Pressure Injury. J Wound Ostomy Continence Nurs 2014; 41(4): 313-34.

109. Conducting a Comprehensive Skin Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar4_pu_skinassesst_final.pdf
     April 01, 2011 - deep tissue injury – Preulceration in the diabetic foot – Inflammation or infection 15 Parameter … – Skin tears (especially forearm of older adults) – Trauma • Make sure to get the etiology right … For each patient, record— • Whether he/she has pressure ulcers • How many pressure ulcers he/she has … • Highest stage of his/her deepest ulcer • Treatment for any existing wounds 32 Reporting Results … Wound care essentials: practice principles. 3rd ed.

110. Indwelling Urinary Catheter Indications Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
     April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention due to a spinal cord injury … the last row on this table), urology consultation should be considered for prostatitis and urethral trauma … Of note, catheters are appropriate in the case of urinary incontinence with open wounds if the urine … cannot be kept from contaminating the wounds using other strategies. … . · Not all open sacral/hip wounds require an indwelling catheter if the wound can be kept clean by other

111. Appendix C1: Falls Assessment Sample | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt1.html
     December 01, 2017 - ___ Psychiatric evaluation Orthostatic Hypotension ___ Reduction of ≥20 mm Hg in systolic pressure

112. Chapter 4. Long Term Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man4.html
     December 01, 2017 - If there is a drop of 20 mm Hg or more in the resident's systolic pressure 1 minute after standing, the … Use of pressure, position, seat belt or other alarm. … Room sensors to detect resident movement; position or pressure alarms on the bed, chair or wheelchair … Trying to climb over bedrails may well result in a serious fall related injury. … For residents who are in danger of head injury, a helmet can provide protection.

113. Appendixes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-appendix.html
     November 01, 2017 - , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … ] OR "Decubitus Ulcer" [tiab] OR "Pressure Sore" [MeSH] OR "Pressure Sore" [tiab] OR "Suspected Deep … 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. … The cost of serious fall-related injuries at three Midwestern hospitals.

114. Appendix B10: Primary Care Provider Fax Report and Orders (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb10pcptxt.html
     December 01, 2017 - ( ) Postural hypotension ≥20 mm Hg drop in systolic pressure with position change

115. Sampleransferandintakenotes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
     June 02, 2025 - disorders/neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound … infection Endocrine/Nutritional/Metabolic  Dehydration  Malnutrition  Uncontrolled diabetes Wound … & Skin  Cellulitis  Edema  Infected wound or decubitus  Jaundice  Rash Fall-Related Injury …  Major injury  Minor injury Non-Fall-Related Injury  Major injury  Minor injury Musculoskeletal … Medication reaction  Mental status change  Mental disorder/psychosis  Neoplasm  Pneumonia  Pressure

116. Appendix B25: Ways Families Can Help Reduce Fall Risk | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb8.html
     December 01, 2017 - Help the patient to use low blood pressure precautions Before the resident gets out of bed, ask her

117. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-handouts.html
     June 01, 2017 - disorders/neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound … and Skin |___| Cellulitis |___| Edema |___| Infected wound or decubitus |___| Jaundice … |___| Rash Fall-Related Injury |___| Major injury |___| Minor injury Non-Fall-Related … Injury |___| Major injury |___| Minor injury Musculoskeletal |___| Joint pain/joint … status change |___| Mental disorder/psychosis |___| Neoplasm |___| Pneumonia |___| Pressure

118. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits - Transfer Note and Intake Note (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.pdf
     June 02, 2025 - disorders/neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound … infection Endocrine/Nutritional/Metabolic  Dehydration  Malnutrition  Uncontrolled diabetes Wound … & Skin  Cellulitis  Edema  Infected wound or decubitus  Jaundice  Rash Fall-Related Injury …  Major injury  Minor injury Non-Fall-Related Injury  Major injury  Minor injury Musculoskeletal … Medication reaction  Mental status change  Mental disorder/psychosis  Neoplasm  Pneumonia  Pressure

119. Table 15A: Outcome Indicators by County Demographics | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15.html
     February 01, 2023 - 8,997 6,894 8,597 6,888 Composite: ACSC Overall 22,706 18,412 21,951 18,376 Pressure … 10,186 7,869 9,760 7,859 Composite: ACSC Overall 24,978 20,372 24,196 20,327 Pressure … 4,856 4,215 4,625 4,246 Composite: ACSC Overall 14,792 13,022 14,282 13,066 Pressure … 3,483 3,293 3,410 3,308 Composite: ACSC Overall 5,671 5,408 5,482 5,469 Pressure … 7,968 6,752 7,567 6,782 Composite: ACSC Overall 20,938 18,196 19,552 18,470 Pressure

120. Introduction to the Quality Indicators Best Practices Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
     June 02, 2025 - 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