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www.talkingquality.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.
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www.talkingquality.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
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www.talkingquality.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 ?
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www.talkingquality.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
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www.talkingquality.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
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www.talkingquality.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
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www.talkingquality.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.
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www.talkingquality.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.
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www.talkingquality.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
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www.talkingquality.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
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www.talkingquality.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.
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www.talkingquality.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
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/intramuscular-injections.pdf
June 01, 2021 - intramuscular (IM) administration is important to make
sure the vaccine does its job and to avoid shoulder injury … and Health Administration (OSHA) regulations
do not require you to wear gloves unless you have
open wounds … Apply gentle pressure to
the injection site for several seconds or longer to minimize bleeding using … For residents who take anticoagulation medications, gentle
pressure may need to be applied longer to … pre-filled autoinjector (at least three doses)
• H1 antihistamine (e.g., diphenhydramine/Benadryl)
• Blood pressure
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0206-technicalspecs.pdf
May 01, 2016 - Exclusions
• Denominator/Numerator Exclusions
o Trauma-related headache or pain (Table … IMG3) on the day of or within 7 days prior to
imaging
o Head trauma or suspected abuse/neglect (Table … 339.43
Other complicated 339.44
OTHER
Post-
traumatic
headache
339.2x
Acute pain
due to
trauma … excision of foreign body from brain 61570
Craniectomy or craniotomy; with treatment of penetrating wound … 852.x
Other/unspecified intracranial hemorrhage following injury 853.x
Intracranial injury of other
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www.talkingquality.ahrq.gov/patient-safety/settings/hospital/resource/safety-assess.html
October 01, 2020 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … The toolkit:
Targets six areas of safety—infections, falls, medication errors, security, injuries of
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www.talkingquality.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - 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
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www.talkingquality.ahrq.gov/data/infographics/hac-rates_2019.html
July 01, 2020 - Description: National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Pressure ulcers: 6% increase. Surgical site infections: 8% increase.
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www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
July 01, 2016 - 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
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www.talkingquality.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
November 01, 2021 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … 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
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www.talkingquality.ahrq.gov/patient-safety/settings/long-term-care/index.html
September 01, 2021 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to … help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.