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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/erepguide.html
December 01, 2016 - Pressure Ulcers at Risk for Delayed Healing.
Weekly Wound Rounds Report. … home chains, and wound centers. … Injury Alliance. … The wound nurse, wound physician, and other disciplines attending wound rounds can see quickly which … If the pressure ulcer shows signs of delayed healing, as recorded on the wound assessment based on the
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/050-dec-implementation-notes.docx
October 01, 2024 - , and stage 1 and 2 pressure injuries. … For patients with recent nasal surgery or trauma—if unable to conduct decolonization, do not apply to … skin, or pressure injuries. … injuries (stage 1 and 2), superficial wounds, and sutured or stapled wounds. … CHG is approved as a wound cleanser.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0206-technicalspecs.pdf
May 01, 2016 - Exclusions
• Denominator/Numerator Exclusions
o Trauma-related headache or pain (Table … IMG3) on the day of or within 7 days prior to
imaging
o Head trauma or suspected abuse/neglect (Table … 339.43
Other complicated 339.44
OTHER
Post-
traumatic
headache
339.2x
Acute pain
due to
trauma … excision of foreign body from brain 61570
Craniectomy or craniotomy; with treatment of penetrating wound … 852.x
Other/unspecified intracranial hemorrhage following injury 853.x
Intracranial injury of other
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
January 01, 2017 - Patients
Adverse Events4
9 patients had 14 adverse events (<1% of activities)
Falls to knees without injury … (5)
Systolic blood pressure <90 mmHg (4)
Oxygen saturation <80% (3)
Nasal feeding tube removal (1) … Systolic blood pressure >200 mmHg (1)
No extubations
No patients required added therapy or increased … sessions (i.e., 6 per 1,000 PT treatment)
80% of events were transient physiological (heart rate, blood pressure … Safety Program for Mechanically Ventilated Patients
5-Year Sustainability of Time to PT
Postacute Lung Injury
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
January 01, 2010 - Smith (2)
Because of his immobility, he develops a pressure ulcer on his sacrum. … Few days later, he develops fever and his blood pressure drops. … Incontinent with open sacral/perineal wounds
Consult with wound care
End of life/hospice
Be sure it … Trauma)
Admitting service (e.g. … Protocolized care for trauma
Incontinence without open sacral or perineal wounds
Pre-operative
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/ereports.html
December 01, 2017 - 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 during … Information that displays on the Weekly Pressure Ulcer Treatment Summary Report, the Weekly Wound Rounds … Uses
DON or ADON, Nurse Manager, Wound Nurse, QI Director
Root Cause Analysis for New Pressure … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
January 01, 2021 - Patient outcome variables
Patient falls and injury falls
• Patient falls/1,000 patient days. … • Injury falls/1,000 patient days. … • Percent of patients with suspected deep tissue injury.
3
Table 1. … • Percent of patients with hospital-acquired suspected deep tissue injury. … ulcers stages III and IV, as well as fall and injury fall
incidence and rates.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/PS-tools-2024.pdf
January 01, 2024 - Web: ahrq.gov/goinghomeguide/
Pressure Ulcers
Preventing Pressure Ulcers: A Toolkit for Improving … Web: ahrq.gov/pressureulcertoolkit
The Pressure Injury Prevention in Hospitals Training
Program supports … the training of hospital staff on how
to implement AHRQ’s Preventing Pressure Ulcers in
Hospitals … injury prevention. … approaches to design that target six areas of
safety: infections, falls, medication errors, security,
injuries
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
May 01, 2017 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management. … McRoberts maneuver used concurrently with suprapubic pressure
[Call time] (hh:mm:ss) ____:____:____ … The ideal approach is for the clinician to put pressure in the antecubital fossa of the posterior arm … This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
February 16, 2011 - Pressure ulcers are sterile wounds.
36. … Pressure ulcers are sterile wounds.
False
36. … If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … unit staff for pressure ulcer practice
Certified Wound Care Nurse
· Assesses wounds, does complex
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find4.html
December 01, 2012 - All but two of the indicators (Pressure Ulcer and Injurious Falls) build on existing AHRQ Prevention … Pressure Ulcer.
Injurious Falls.
-
www.ahrq.gov/funding/grantee-profiles/grtprofile-nishisaki.html
July 01, 2025 - Advanced Education and Innovation, Children’s Hospital of Philadelphia Chair, Pediatric Acute Lung Injury … experiencing respiratory failure, which is caused by various conditions, including pneumonia, asthma attacks, injuries … in five children who undergo the procedure face complications, including breathing issues, low blood pressure … Nishisaki also serves as Chair of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pptx
October 01, 2015 - in October 2015:
Addition of information relevant to ambulatory and managed care encounters
Expanded injury … Postoperative pulmonary embolism or deep vein thrombosis
PSI 13 Postoperative sepsis
PSI 14 Postoperative wound … dehiscence
PSI 15 Accidental puncture or laceration
PSI 16 Transfusion reaction
PSI 17 Birth trauma-injury … to neonate
PSI 18 Obstetric trauma-vaginal delivery with instrument
PSI 19 Obstetric trauma-vaginal … PDI 09 Postoperative Respiratory Failure Rate
PDI 10 Postoperative Sepsis Rate
PDI 11 Postoperative Wound
-
www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
October 01, 2015 - Teamwork and Communication Definitions and Tools
Several examples of severe patient injury … Paraplegia (inability to walk)
Ultimately, the patient underwent back surgery to decompress the pressure … The virulent organism caused a severe infection and irreversible injury to the patient. … She was found to have a fever of 102 °F, and her blood pressure dropped to 90 systolic.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14.html
February 01, 2023 - 7,561
7,177
Composite: ACSC Overall
19,494
19,068
22,370
17,903
19,831
18,937
Pressure … 8,666
8,172
Composite: ACSC Overall
21,480
21,331
24,806
19,795
22,008
20,929
Pressure … 4,449
4,235
Composite: ACSC Overall
13,871
12,234
15,225
12,474
13,703
13,045
Pressure … 3,525
3,189
Composite: ACSC Overall
5,684
5,096
5,763
5,286
5,764
5,235
Pressure … 10,552
Composite: ACSC Overall
25,931
27,847
34,209
23,478
26,582
26,462
Pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
June 02, 2025 - 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
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/handouts.html
December 01, 2017 - We record onset day, stage, and surface area of each pressure ulcer during wound rounds. … ulcer healing and you will be able to identify wounds suspected of infection. … Pressure Injury Alliance's Prevention and Treatment of Pressure Ulcers Guidelines
|___| Wound, Ostomy … Ulcer Report
Pressure Ulcers At Risk for Delayed Healing
Weekly Wound Rounds Report
Weekly Pressure … Pressure Ulcers at Risk for Delayed Healing with wound rounds.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4e_combo_psi08-postophipfx-bestpractices.pdf
May 20, 2016 - In 2008 the Centers for
Medicaid & Medicare Services (CMS) identified falls and trauma—including fractures—as … Prevention
Protocol
Use a standardized fall prevention protocol to help reduce falls
and associated injury … /fallspx/fallspxmanual.pdf
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Transforming care at the bedside how-to guide: reducing patient injuries from
falls.http://www.ihi.org … High blood pressure and bone-mineral loss in elderly white women: a prospective
study.
-
www.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
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
November 01, 2021 - 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