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  1. 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.
  2. 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
  3. 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 ?
  4. 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
  5. 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
  6. 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
  7. 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.
  8. 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.
  9. 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 PressureInjury 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
  10. 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
  11. 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 PressureInjury 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.
  12. 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
  13. 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
  14. 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
  15. 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 PressureInjury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … The toolkit: Targets six areas of safety—infections, falls, medication errors, security, injuries of
  16. 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
  17. 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 injuriesPressure ulcers: 6% increase. Surgical site infections: 8% increase.
  18. 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
  19. 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
  20. 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.

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