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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 5 Tools
Action Plan Tool … to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices
Tool 5C: Assessing Comprehensive … Assessment
Tool 5D: Assessing Standardized Risk Assessment
Tool 5E: Assessing Care Planning
AHRQ Pressure … stakeholders and staff
Root cause analysis is conducted for each fall with at least moderate level of injury … admission nursing assessment, subsequent nursing progress notes, or any notes specifically documenting pressure
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/065-dec-staff-faqs-decolonization.docx
October 01, 2024 - Be especially thorough if there are any nearby wounds, pressure injuries, or breaks in the skin. … Use the CHG on superficial wounds and stage 1 and 2 pressure injuries. … Wound Cleaning
For what types of wounds is CHG safe? … CHG can be applied to any superficial wounds, including stage 1 and 2 pressure injuries, friable skin … and stage 1 and 2 pressure injuries.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
June 02, 2025 - (Tool 2C)
Present the assessment of current pressure injury prevention policies and procedures. … Link the Pressure Injury Prevention Program with quality improvement. … Injury Implementation Team
Wound Care Team
Unit Team
12
Collaborative Relationships
Unit-Based Team … Current Pressure Injury Processes
Understand current processes in patient care units. … Let’s look at completed Tool 2D now.
19
Assess Pressure Injury Screening Practices
Tool 2E
20
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 3 Tools
3A: Pressure Ulcer … If a skin disruption is found, the type of skin injury will need to be identified. … Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … A wound/ostomy nurse consult revealed he has a slightly pink coccyx area (base of spinal column).
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides2.html
October 01, 2017 - (Tool 2C)
Present the assessment of current pressure injury prevention policies and procedures. … Slide 5: Expected Outcomes
Begin to write a draft Pressure Injury Prevention Action Plan, tailored … Members who influence the areas involved in pressure injury prevention. … Slide 12: Collaboration
Pressure Injury Implementation Team.
Wound Care Team. … Wound Care Team: Interdisciplinary group of experts who provide day-to-day care of skin and wound needs
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
December 01, 2017 - Use Low Blood Pressure Precautions
Slide 1. … Paralysis, tremors
Loss of joint mobility, contractures
Lower extremity weakness
Drop in blood pressure … Physical Restraints
Physical restraints increase the likelihood of serious injury resulting from … Consequences of Falls
Serious injury such as hip fracture
Increased risk of death associated … Use Low Blood Pressure Precautions
For residents with low blood pressure:
Sit on edge of bed
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www.ahrq.gov/topics/healthcare-costs.html
Patient Falls by 21 Percent
Chartbook on Care Affordability
Connecticut Hospital Reduces Pressure … Injuries Using AHRQ Toolkit
Estimating the Costs of Primary Care Transformation: A Practical Guide
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - due to procedures,
as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries
increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/Pressure
Injuries
Obstetric Adverse Events
Falls
Clostridioides difficile
Infections
Central … Ulcers/
Pressure Injuries
21.7 23.5 22.7 23.0 6%
Surgical Site Infections 2.5 2.5 2.5 2.7 8% … Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs for 17 procedures w/CDC SCIP
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - o Wound edges. … -
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-
injury/
Staff … Washington, DC: National Pressure Ulcer
5 Tool D.4a
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apd.html
October 01, 2017 - Pressure Injury Prevention Program Implementation Guide
Appendix D. … Injury Prevention Program Implementation Guide
Overview
Get Ready
Pressure Injury Prevention Program … Hospital Practice Insights: Challenges and Solutions
Production Agenda: Pressure Injury … Injury Rates and Pressure Injury Prevention Practices .
25
Measuring pressure injury … Injury Rates and Pressure Injury Prevention Practices
3:50–3:55
5
Closing
Evaluation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - hospital mattress.7,8-11
o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in
hospitalised patients. Int Wound J 2010;7:358-65.
7.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4b_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - hospital mattress.7,8-11
o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in
hospitalised patients. Int Wound J 2010;7:358-65.
7.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-2-tech-specs.pdf
December 14, 2011 - ulcers and deep tissue injury in critically ill and injured children. … Wound assessment and decision making options. … These patients may be admitted with existing wounds and they may develop impaired skin
integrity due … Describes the different types of injuries that critically ill children, including infants, experience … Wound Ostomy and Continence Nurses Society.
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - • Patient safety concerns such as falls,
pressure injuries, and adverse medication
events were reported … Pressure Injury
Among the pressure injury events (n = 10; 3.3%), several records identified the development … of pressure
injuries due to the interaction between patient pronation and poor patient mobility. … Four records identified
the development of multiple pressure injuries to the lips, tongue, ears, and … The remaining pressure injuries were identified across multiple other contact points such as
the coccyx
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www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-fac-guide.html
February 01, 2017 - There’s also a cyclical type of trauma that occurs, often called “atelectrauma.” … and adjust the ventilator to try to maintain the plateau pressures below 30 centimeters of water; and … There’s some sort of priming insult, such as pneumonia, sepsis, severe trauma, noncardiogenic shock, … Insults secondary to mechanical ventilation include ventilation-induced lung injuries. … Plateau pressures were significantly lower.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mvp/ltvv-intro/ltvv-intro-facguide.docx
January 01, 2017 - There’s also a cyclical type of trauma that occurs, often called “atelectrauma.” … and adjust the ventilator to try to maintain the plateau pressures below 30 centimeters of water; and … There’s some sort of priming insult, such as pneumonia, sepsis, severe trauma, noncardiogenic shock, … Insults secondary to mechanical ventilation include ventilation-induced lung injuries. … Plateau pressures were significantly lower.
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www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-slides.html
February 01, 2025 - Pressure limited. … Slide 22: LTVV in ARDS Large V t and the high pressures it generates were harmful 3,4 LTVV became the … to measure transpulmonary pressures clinically). … Trauma. Noncardiogenic shock. Multiple transfusions. Cardiopulmonary bypass. … Trauma. Pancreatitis. Post-circulatory arrest. Multiple transfusions. Severe burns.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - due to
procedures, as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from
2015 to 2016 … Ulcers/
Pressure Injuries
21.7 23.5 22.7 23.0 6% 17.4
Surgical Site
Infections
2.5 2.5 2.5 … Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs for 17 procedures w/CDC SCIP … Ulcers/Pressure
Injuries
Surgical
Site
Infection
NHSN SSIs for 17
procedures
w/CDC SCIP+5
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www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
April 01, 2025 - the population at risk numbered at least 100, the highest rates for both 2021 and 2022 were worsening pressure … injuries that were present on admission (2021: 4.9%, 2022: 6.0%), hypoglycemic events (4.7% for both … Pressure Injury. Surgery/Anesthesia. Venous Thromboembolism. Other. … determined that national efforts to reduce hospital-acquired conditions such as adverse drug events and injuries
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www.ahrq.gov/topics/outcomes.html
Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools
Connecticut Hospital Reduces Pressure … Injuries Using AHRQ Toolkit
Georgetown University Family Nurse Practitioner Program Trains Hundreds