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21. AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html
    May 01, 2016 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Pressure ulcers remain a serious problem in nursing homes despite regulatory and market approaches to … Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer … Median annual nursing home pressure ulcer prevalence was 7.5 percent in 2009, with associated costs of … Materials Self-Assessment Worksheet for Pressure Ulcer Prevention .

22. Declines in Hospital-Acquired Conditions (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
    January 01, 2019 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … CLABSI+ -6% Clostridioides difficile Infections -37% Falls -5% Obstetric Adverse Events -3% Pressure

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

24. Fall Prevention in Hospitals—Webinars | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/webinars/index.html
    September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Assessment Tools in Care Planning  (25 min) ( PDF of the Slides , 2.16 MB) Measuring Fall and Fall-Related Injury … Network Webinars Creating Control Charts To Interpret Fall Data (62 min) Critical Thinking for Fall Injury … Prevention Care Planning (61 min) Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries

25. Fall Prevention in Hospitals Training Program | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/index.html
    September 01, 2018 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Module 3 Tools ( MS Word , 268 KB) Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … Network Webinars Related AHRQ Resources Preventing Falls in Hospitals Toolkit Pressure … Injury Prevention in Hospitals Training Program Page last reviewed September

26. C1 Prioritization Worksheet (xls file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    July 01, 2016 - Patient Safety PSI 03 Pressure Ulcer   PSI 06 Iatrogenic Pneumothorax PSI 07 Central Venous Catheter-Related … Perioperative Pulmonary Embolism or Deep Vein Thrombosis   PSI 13 Postoperative Sepsis PSI 14 Postoperative Wound … Dehiscence PSI 15 Accidental Puncture or Laceration Obstetric PSI 17 Birth Trauma-Injury to Neonate …   PSI 18 Obstetric Trauma-Vaginal Delivery With Instrument   PSI 19 Obstetric Trauma-Vaginal Delivery … 09 Postoperative Respiratory Failure Rate PDI 10 Postoperative Sepsis Rate PDI 11 Postoperative Wound

27. Initial Risk Assessment for Immobility-Related Pressuer Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-203-fullreport.pdf
    April 10, 2017 - Ulcer Advisory Panel (EPUAP) — “A pressure ulcer is localized injury to the skin and/or underlying … ulcers are a serious iatrogenic injury. … They may have preexisting wounds or altered skin integrity due to a variety of factors related to their … Are pressure ulcers preventable? A survey of experts. Adv Skin Wound Care 2001; 14(5):244-8. … Unavoidable Pressure Injury. J Wound Ostomy Continence Nurs 2014; 41(4): 313-34.

28. Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/research/findings/studies/index.html?page=1
    January 01, 2024 - and Wounds (207) Inpatient Care (220) Intensive Care Unit (ICU) (264) Kidney Disease and … Outcome measures included hypertension, systolic blood pressure >130 mmHG, and hyperglycemia. … center (NTC) and were diagnosed with a traumatic injury with an injury severity score of greater than … , major chest injury, and presentation at a teaching hospital. … , Injuries and Wounds Cron DC , Braun HJ , Ascher NL Sex-based disparities in access to

29. References | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/hai/pfp/hacrate2013-refs.html
    October 01, 2015 - Injury From Falls Barrett JA, Bradshaw M, Hutchinson K, et al. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers Agency for Healthcare Research and Quality.

30. Introduction to the Quality Indicators Best Practices Tool (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
    June 05, 2016 - Best practices forms exist for the following 14 PSIs: • PSI 03 Pressure Ulcer Rate • PSI 05 Retained … Pulmonary Embolism or Deep Vein Thrombosis Rate • PSI 13 Postoperative Sepsis Rate • PSI 14 Postoperative Wound … 03 Neonatal Blood Stream Infection Rate • PDI 01 Accidental Puncture or Laceration Rate • PDI 02 Pressure … Postoperative Respiratory Failure Rate • PDI 10 Postoperative Sepsis Rate • PDI 11 Postoperative Wound … • PSI 17 Birth Trauma Rate―Injury to Neonate: The existing literature on birth trauma and injury

31. 4 Tk2 T1-Medical Care Referral Form (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
    May 01, 2014 - Positive culture If yes, positive for:_______________________________ CURRENT VITAL SIGNS Blood pressure … New or increasing pus draining from wound Y N ? New breakdown Y N ? … New or expanding redness around wound Y N ? Pain / tenderness Y N ? Warmth Y N ? … Suspected minor injury Yes No ? Suspected serious injury Yes No ?

32. Section 6-B, PMCoE PICU Expert Workgroup and Leadership Team Roster (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-6-b-pmcoe-picu-expert-workgroup.pdf
    September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to

33. Section 6-B, Expert Workgroup Roster and Materials (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
    September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to

34. PMCoE PICU Expert Work Group and Leadership Team Roster (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-6-b-workgroup.pdf
    September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to

35. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/index.html
    March 01, 2024 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … pressure ulcer prevention practices through an interdisciplinary approach to care. … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. … injury prevention.

36. Overuse of Imaging for the Evaluation of Children with Post-Traumatic Headache (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-fullreport.pdf
    December 17, 2019 - , seizure associated with trauma, loss of consciousness associated with trauma, repeated vomiting, documented … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … Was there documentation of increased intracranial pressure? … The sensitivity of claims for identification of indicators of increased intracranial pressure was 8.1 … in a non-trauma center.

37. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Slide Presentation | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
    September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … None or no injury: The patient is free of injuries (no signs or symptoms) resulting from a fall … Death: The patient died as a result of injuries sustained from the fall (not from physiologic events … Slide 13: NDNQI Definitions of Fall Injury None: No injury Minor: Resulted in bruise, abrasion

38. AHRQ Tools To Reduce Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/hai/hac/tools.html
    March 01, 2024 - Hospitals Central line-associated blood stream infections (CLABSI): Tools for Reducing CLABSI Injuries … Non-ICU Patients With Devices Obstetrical adverse events: Toolkit for Improving Perinatal Safety Pressure … ulcers: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care Surgical

39. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Training Guide | Agency for Healthcare Research and Quality
    www.monahrq.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
    September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … injuries (no signs or symptoms) resulting from the fall. … treating with ice, cleaning the wound, limb elevation, topical medication, or a bruise or abrasion. … Interventions to prevent falls and fall injuries are tracked.

40. Documentation and Coding for Patient Safety Indicators (pdf file)
    www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
    March 15, 2016 - PDI 02 Pressure Ulcer Rate (stage III, IV, Unstageable) Diagnosis and site of pressure ulcer must … PSI 18, PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without … X PDI 11 Postoperative Wound Dehiscence Rate X Depth of the wound dehiscence: external/superficial … X PSI 14 Postoperative Wound Dehiscence X Depth of the wound dehiscence: external/superficial vs … PSI 18 PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without