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61. 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

62. 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

63. AHRQ-Funded Patient Safety Project Highlights (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
    August 01, 2025 - ■ Improve patient outcomes (e.g., reduced pressure injuries, infection rates, falls). … , and pressure injuries compared to normal weight. … There were significant differences in NHs with high and low rates of falls, falls with injuries, pressure … Results showed there was no overall decline in pressure injury rates for treatment relative to matched … /index.html https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html

64. 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").

65. 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.

66. 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?

67. 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.

68. 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

69. 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

70. 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.

71. 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?”

72. On-Time Pressure Ulcer Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/assessment.html
    December 01, 2017 - On-Time Pressure Ulcer Assessment AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer … Healing The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound … In partial thickness wounds it can occur throughout the wound bed as well as from the wound edges. … In full thickness wounds it occurs from the edges only. … Stage 4             Unstageable             Suspected Deep Tissue Injury

73. 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).

74. 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

75. AHRQ Safety Program for MRSA Prevention
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/062-protocol-training-decolonization-with-chg.pptx
    October 01, 2024 - Superficial pressure injuries (stages 1 and 2) CHG should also be applied over sutured or stapled wounds … Clean wound carefully with CHG. … Apply CHG with firm pressure, unless the wound is over a bony prominence. … Using the CHG on superficial wounds, and stage 1 and 2 pressure injuries. … Refer to the slides on Wound Care.

76. 3. What are the best practices in pressure ulcer prevention that we want to use? | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
    October 01, 2014 - Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and … Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients … The level and completeness of the spinal cord injury is critical in this determination. … Adv Skin Wound Care 2009;22(2):83-92. Magan MA, Maklebust J. … Adv Skin Wound Care 2008;21(3):124-33.

77. 3. What are the best practices in pressure ulcer prevention that we want to use? | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
    October 01, 2014 - Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and … Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients … The level and completeness of the spinal cord injury is critical in this determination. … Adv Skin Wound Care 2009;22(2):83-92. Magan MA, Maklebust J. … Adv Skin Wound Care 2008;21(3):124-33.

78. Appendix B5: Falls Assessment Cue Sheet | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb3.html
    February 01, 2023 - Take the resident's blood pressure in the right arm unless otherwise indicated and take an apical heart … Determine if there is a reduction of ≥20 mm Hg in systolic pressure for postural hypotension.

79. 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.

80. 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