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181. 050-Dec-Implementation-Notes (doc file)
     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.

182. Table 14A: Outcome Indicators by County Supply of Health Care Providers | Agency for Healthcare Research and Quality
     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

183. Examples of Patient Harm Related to Invasive Devices | Agency for Healthcare Research and Quality
     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.

184. Selected Best Practices and Suggestions for Improvement (pdf file)
     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.

185. Background for AHRQ Quality Indicators
     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

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

187. Long-term Care Resources | Agency for Healthcare Research and Quality
     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

188. On-Time Pressure Ulcer Healing Facilitator Training Implementation of the Healing Reports: Handouts | Agency for Healthcare Research and Quality
     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.

189. C1 Prioritization Matrix (xls file)
     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

190. Table 17C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17c.html
     February 01, 2023 - 5,049 3,932 Composite: ACSC Overall 15,281 10,642 14,988 12,306 15,447 12,117 Pressure … Falls 76 51 101 45 98 47 Outcome Indicator Prevalence of High Blood Pressure … 4,416 4,102 5,111 4,002 Composite: ACSC Overall 13,885 11,778 15,231 12,519 Pressure

191. Table 17B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17b.html
     February 01, 2023 - 10,530 7,005 Composite: ACSC Overall 24,760 16,334 23,622 19,729 26,330 18,086 Pressure … 397 350 396 366 462 324 Outcome Indicator Prevalence of High Blood Pressure … 8,314 8,522 10,408 7,479 Composite: ACSC Overall 21,408 21,005 25,803 19,316 Pressure

192. Table 17D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17d.html
     February 01, 2023 - 3,815 3,120 Composite: ACSC Overall 6,079 4,558 5,662 5,312 6,245 5,000 Pressure … Falls 81 60 90 55 92 60 Outcome Indicator Prevalence of High Blood Pressure … 3,481 3,208 3,831 3,228 Composite: ACSC Overall 5,719 5,011 6,399 5,136 Pressure

193. Table 17A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17.html
     February 01, 2023 - 9,215 6,184 Composite: ACSC Overall 22,374 14,832 21,534 17,751 23,720 16,492 Pressure … 316 271 324 280 375 250 Outcome Indicator Prevalence of High Blood Pressure … 7,298 7,429 9,114 6,570 Composite: ACSC Overall 19,447 18,724 23,221 17,538 Pressure

194. Table 17G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17g.html
     February 01, 2023 - 13,941 8,615 Composite: ACSC Overall 31,820 19,437 32,312 23,141 34,235 21,902 Pressure … 568 461 588 484 677 430 Outcome Indicator Prevalence of High Blood Pressure … 10,221 11,658 13,626 9,337 Composite: ACSC Overall 25,759 28,549 32,778 23,897 Pressure

195. Puh-Electronic-Reports (pdf file)
     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

196. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2013.html
     November 01, 2015 - 2 In 2010 an HHS Office of the Inspector General (OIG) team identified the rate of harm—that is, injuries … The estimate for deaths associated with pressure ulcers was based primarily on the paper by Zhan and … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … This estimate is based on analysis of data from HCUP identifying injuries in 7.45 million hospital discharge … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure

197. Table 17F: HCBS Population Ages 18-64 Without Intellectual/Developmental Disabilities or Serious Mental Illness | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17f.html
     February 01, 2023 - 7,139 5,429 Composite: ACSC Overall 23,940 16,507 25,790 18,529 23,803 18,978 Pressure … 147 123 175 119 170 116 Outcome Indicator Prevalence of High Blood Pressure … 6,119 6,072 7,171 5,539 Composite: ACSC Overall 21,607 19,235 23,468 19,546 Pressure

198. Table 17E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17e.html
     February 01, 2023 - 8,838 5,914 Composite: ACSC Overall 20,734 15,368 19,563 17,756 23,009 16,087 Pressure … 253 224 263 220 323 194 Outcome Indicator Prevalence of High Blood Pressure … 6,956 7,098 7,925 6,580 Composite: ACSC Overall 19,175 17,427 20,509 17,826 Pressure

199. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … captures the specific type of physical injury sustained in the fall as TYPE OF INJURY AS RESULT OF … that they represent minor injuries such as soreness, bumps, and minor abrasions. … and the type of the injury. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

200. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=8
     January 01, 2024 - Publication Date: March 2015 Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Coordination, Health Information Technology and Health Information Exchange, Human and Environmental Factors, Pressure … Information Exchange Publication Date: December 2014 Communication To Prevent and Respond to Medical Injuries