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141. Statistical Brief #96: Potentially Preventable Hospitalizations among Medicare-Medicaid Dual Eligibles, 2008 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb96.pdf
     September 01, 2010 - eligibles accounted for about one-third of all Medicare hospital stays with a principal diagnosis of pressure … ■ Among the nine selected potentially preventable hospitalizations, stays for pressure ulcers had … Pressure ulcers are a condition that typically results from prolonged periods of uninterrupted pressure … Injurious falls are a common cause of fatal injuries among elderly adults ages 65 years and older. … Common fall-related injuries include fractures, open wounds, and head traumas, and are serious enough

142. DXCCSR-ChangeLog-v20191-v20201 (xls file)
     hcup-us.ahrq.gov/toolssoftware/ccsr/DXCCSR-ChangeLog-v20191-v20201.xlsx
     October 01, 2019 - Pressure-induced deep tissue damage of left elbow SKN003 Pressure ulcer of skin L89106 Pressure-induced … Pressure ulcer of skin L89216 Pressure-induced deep tissue damage of right hip SKN003 Pressure ulcer … Pressure-induced deep tissue damage of unspecified buttock SKN003 Pressure ulcer of skin L89316 Pressure-induced … Pressure ulcer of skin L89606 Pressure-induced deep tissue damage of unspecified heel SKN003 Pressure … L89626 Pressure-induced deep tissue damage of left heel SKN003 Pressure ulcer of skin L89816 Pressure-induced

143. 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.

144. 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

145. Procedural Mishap: Learning Curve? | PSNet
     psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
     April 28, 2021 - The anesthesiologist then noted a rapid decrease in the patient’s blood pressure and increasing tachycardia … , indicating a possible vascular injury. … Pressure was applied and vascular surgery was consulted. … of underreporting of vascular injury. … How can this type of injury be prevented?

146. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49389/psn-pdf
     February 01, 2003 - The anesthesiologist then noted a rapid decrease in the patient’s blood pressure and increasing tachycardia … , indicating a possible vascular injury. … Pressure was applied and vascular surgery was consulted. … underreporting of vascular injury. … How can this type of injury be prevented?

147. 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

148. Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings. | PSNet
     psnet.ahrq.gov/issue/estimating-economic-cost-nurse-sensitive-adverse-events-amongst-patients-medical-and-surgical
     July 11, 2018 - Some adverse events are sensitive to aspects of nursing care , including pressure injuries , falls, … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure

149. Surgical robot examined in injuries. | PSNet
     psnet.ahrq.gov/issue/surgical-robot-examined-injuries
     April 27, 2016 - Newspaper/Magazine Article Surgical robot examined in injuries. … Citation Text: Surgical robot examined in injuries. Carreyrou J. … explains that such errors may have been exacerbated by inadequate clinician training and production pressures … Cite Citation Citation Text: Surgical robot examined in injuries

150. 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

151. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
     December 01, 2010 - injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, … Slough or eschar may be present on some parts of the wound bed. … Suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled … Ulcers (2) Skin changes can appear days after the tissue injury Pressure ulcers often cause pain initially—may … Guidelines for the prevention of pressure ulcers. Wound Rep Reg. 2008; 16:151-168.

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45202/psn-pdf
     October 08, 2016 - Towards international consensus on patient harm: perspectives on pressure injury policy. … Towards international consensus on patient harm: perspectives on pressure injury policy. … https://psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury … https://psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-policy … https://psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-policy

153. 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.

154. 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").

155. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
     October 01, 2011 - year-old man with insulin-dependent diabetes, hypertension, and chronic kidney disease was admitted to a trauma … service after injuries suffered from an assault and battery. … The patient’s injuries included a left shoulder dislocation and a minimally displaced fracture of a thoracic … In reviewing the medical records, the PT noted the initial shoulder injury on admission. … ICU (4) In addition to providing a general assessment, the PT expressed concern that the shoulder injury

156. 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.

157. 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?

158. Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice. | PSNet
     psnet.ahrq.gov/issue/barriers-and-facilitators-reporting-medical-device-related-pressure-ulcers-qualitative
     April 07, 2019 - Study Barriers and facilitators to reporting medical device-related pressure ulcers … Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration … Hospital-acquired pressure ulcers, categorized as a never event, are underreported , particularly when … Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting … injuries.

159. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74252/psn-pdf
     January 12, 2022 - Or they were used to a certain type of protective foam to prevent pressure injuries and now they must … With regard to pressure injuries for patients in the prone position, staff had to think about how to … We saw pressure injuries and as soon as these events occurred, we saw staff problem-solving and doing … The other thing that we saw related to pressure injuries was a type of skin lesion the National Pressure … COVID skin looks very much like deep tissue injury, or other types of pressure injury, but is actually

160. 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