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61. Data Submission Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2024.xlsx
    January 01, 2024 - Documented within 24 hours of admission 0.9% 35 Stage/Category IV Unknown * * Suspected Deep Tissue Injury … Documented within 24 hours of admission 71.0% 2,897 Suspected Deep Tissue Injury No risk assessment … documented * * Suspected Deep Tissue Injury Not on admission, but documented after discovery or advancement … of pressure ulcer 78.6% 11 Suspected Deep Tissue Injury Not on admission, but documented before discovery … or advancement of pressure ulcer * * Suspected Deep Tissue Injury Unknown 69.4% 1,111 Unstageable

62. Presentation: Program Overview
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mvp/ltvv-intro/ltvv-intro-slides.pptx
    January 01, 2017 - cc/kg)1 Additional studies and meta-analysis showed large tidal ventilation and the resulting high pressures … regulated volume controlled (PRVC) Pressure support (PS) Continuous positive airway pressure (CPAP) … #› AHRQ Safety Program for Mechanically Ventilated Patients 21 LTVV in ARDS Large Vt and the high pressures … Emerging Evidence5 Multi-hit theory Priming: initial insult → at risk for ARDS Pneumonia Sepsis Trauma … inhalation Pulmonary contusion Pulmonary vasculitis Sepsis Systemic inflammatory response syndrome Trauma

63. On-Time Pressure Ulcer Healing: Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/intro.html
    December 01, 2017 - , and other clinical details known to affect wound healing, such as nutrition, temperature, and ulcer … For example, during wound rounds, the wound nurse may prefer having treatment details for each ulcer … Healing Report ), and the entire team may attend wound rounds with a copy of the Weekly Wound Rounds … Pressure Ulcers At Risk for Delayed Healing Weekly Wound Rounds Report Weekly Pressure … Advisory Panel and Pan Pacific Pressure Injury Alliance.

64. Appendix B11: Fall Interventions Plan | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6.html
    February 01, 2023 - Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions __ Low blood pressure … __ Behavior management strategies __ Increase assistance and surveillance    __ Position or pressure … _ Increase activities involvement    __ Other ___________________________ __ Reduce risk of injury

65. Appendix C8: Fall Interventions Plan Sample | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt8.html
    December 01, 2017 - Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions ___ Low blood pressure … Behavior management strategies _X_ Increase assistance and surveillance    _X_ Position or pressure … Increase activities involvement    ___ Other ___________________________ _X_ Reduce risk of injury

66. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
    January 01, 2022 - Injuries or Complications of Pressure Injuries Present on Admission (POA) (4.9%), and Hypoglycemic … Injuries or Complications of Pressure Injuries POA (13.4% vs. 4.7%) and Catheter- associated Urinary … Injuries or Complications of Pressure Injuries POA is significantly higher (8.4% vs. 4.4%) for the … injuries or complications of pressure injuries present on admission (POA) was significantly higher … injuries or complications of pressure injuries present on admission (13.4% vs. 4.7%) and catheter-associated

67. Hospital Resources | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/about.html
    December 01, 2017 - Process Millions of patients visit hospital emergency departments (EDs) each year for a variety of injuries … Pressure Injury Prevention in Hospitals Training Program AHRQ developed the Pressure Injury Prevention … injury prevention program. … Preventing Pressure Ulcers in Hospitals Each year, more than 2.5 million people in the United States … develop pressure ulcers.

68. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
    April 01, 2021 - Identify areas of skin at risk for developing pressure ulcers (recently renamed by expert organizations … as pressure injury) from exposure to intense or prolonged pressure, moisture, friction, and shear and … The M-Safety Lab created a patient safety display—a digital bedside display of catheter and wound information … display improved provider's awareness of indwelling urinary catheters, central venous catheters, and pressure … injuries (formerly called "pressure ulcers").

69. Describe How a Plan or Provider Can Influence a Quality Measure | Agency for Healthcare Research and Quality
    www.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.

70. Self-Assessment Worksheet for Pressure Ulcer Healing | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/saworksheet.html
    December 01, 2017 - the On-Time electronic reports into current workflow to help inform pressure ulcer wound interventions … , and Pan Pacific Pressure Injury Alliance’s Prevention and Treatment of Pressure Ulcers Guidelines … ___ Wound, Ostomy, and Continence Nurses Society (WOCN) Pressure Ulcer Guidelines ___ Other (specify … ___ ___   Selection of dressings based on wound characteristics? … ___ ___   Appropriate use of topical wound agents?

71. Appendix B. Prioritize Opportunities for Improvement | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apb.html
    October 01, 2017 - Pressure Injury Prevention Program Implementation Guide Appendix B. … Injury Prevention Program Implementation Guide Overview Get Ready Pressure Injury Prevention Program … Firm up your Implementation Team Leader, Core Team, Pressure Injury Team, and pressure injury champions … They might include ideas such as universal pressure injury precautions, pressure injury risk screening … Alternatively, you might decide to group ideas under the major categories in the pressure injury clinical

72. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
    January 01, 2021 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … Injuries were divided into three groups: No Injury where the incident did not result in harm, Injury … that they represent minor injuries such as soreness, bumps, and minor abrasions. … Injuries were divided into two groups: Fall considered unassisted and Fall known to be assisted. … the most advanced stage of the pressure ulcer or suspected Deep Tissue Injury being reported?”

73. Appendix B8: Unsafe Behavior Worksheet (Text Description) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
    December 01, 2017 - ( ) Postural hypotension ≥20 mm Hg drop in systolic pressure with position change … Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions __ Low blood pressure … __ Behavior management strategies __ Increase assistance and surveillance    __ Position or pressure … _ Increase activities involvement    __ Other ___________________________ __ Reduce risk of injury

74. Appendix B31: Engineer Wheelchair Inspection | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb31.html
    December 01, 2017 - Use a tire gauge to check tire pressure if the tire is air-filled. If it is low, look for leaks. … of dirt and grime, remove and clean. ___ If air-filled tire is soft, inflate until firm and at the pressure … Brake Check The tires must be filled to the correct pressure before checking brakes.

75. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
    December 01, 2017 - measures that include falls, residents who fall, residents with two or more falls and fall related serious injuries … Changes in staff organization Reduction of survey tags and lawsuits related to falls and injuries … Include alarms attached to a wheelchair and consider all types of pressure or position change alarms … Item 14 asks if the resident's blood pressure was taken after the fall. … across from the injury site and specify the type of injury.

76. Low Tidal Volume (Lung Protective) Ventilation Literature Review | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-lit-review.html
    January 01, 2017 - trial with 20 patients without lung disease, requiring mechanical ventilation admitted to either a trauma … regression analysis adjusted for baseline characteristics and underlying ARDS risk factors (sepsis, trauma … concentrations of TNF-alpha and of slCAM-1; Reductions of V t , with subsequently decreased peak airway pressures … The plateau airway pressures of group PV were lower than those groups of CV+PEEP (p=0.02) and CV+ZEEP … , such as multiple transfusions, trauma, sepsis, or high-risk surgery.

77. Final Progress Report: Analysis of Factors Associated With Clinical Checklist Compliance (pdf file)
    www.ahrq.gov/sites/default/files/2024-05/sarcevic-report.pdf
    January 01, 2024 - , and (4) patients with external injuries. … 1(0-3) 0(1-3) Injury 0(0-2) 0(0-1) External 0.014 0.053 <.001* <.001* 0.92 0.13 No injury 1(0-1.5) … with penetrating injuries and those with a blunt injury. … Of 187 patients, 111 (59.4%) had external injuries. … without external injuries (p<.001, Table 1).

78. Appendix B7: Wheelchair Seating Assessment (Text Description) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manwsa.html
    December 01, 2017 - Skin Breakdown __  Jell or air cushion to assist in healing skin ulcer __  Cushion to distribute pressure … ) thoracic region at most extreme point of scoliotic curve; 2) just under axilla, avoiding axillary pressure

79. Appendix A. RACI Chart | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apa.html
    October 01, 2017 - Pressure Injury Prevention Program Implementation Guide Appendix A. … RACI Chart Previous Page Next Page Table of Contents Pressure Injury Prevention Program … Implementation Guide Overview Get Ready Pressure Injury Prevention Program Phases Appendix A

80. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
    November 01, 2017 - Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .