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181. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. | PSNet
     psnet.ahrq.gov/issue/delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations
     March 25, 2020 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … March 18, 2020 Applying modern error theory to the problem of missed injuries in trauma

182. Differences in the reporting of care-related patient injuries to existing reporting systems. | PSNet
     psnet.ahrq.gov/issue/differences-reporting-care-related-patient-injuries-existing-reporting-systems
     December 12, 2018 - Commentary Differences in the reporting of care-related patient injuries to existing … Differences in the reporting of care-related patient injuries to existing reporting systems. … Differences in the reporting of care-related patient injuries to existing reporting systems. … Related Resources From the Same Author(s) Success in hospital-acquired pressure

183. 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.

184. 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.

185. A Tale of Two Falls | PSNet
     psnet.ahrq.gov/web-mm/tale-two-falls
     March 27, 2024 - treated with albuterol without improvement, which prompted the initiation of bilevel positive airway pressure … She sustained head trauma, blunt trauma of the cervical spine, right rib fractures, and a right femur … initial ED presentation, she was alert and oriented, and her vital signs were stable, with a blood pressure … We do not know if the patient’s fall at home resulted in head trauma, which may have predisposed her … second case or contributed to a worse injury.

186. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864865/psn-pdf
     March 20, 2024 - demands during the crisis to affect falls, medication safety, healthcare associated infections, and pressure … injuries.

187. 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

188. Psi90 Factsheet Faq (pdf file)
     qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf
     August 31, 2016 - In addition, patients with any diagnosis of acute brain and/or spinal injury were removed from the … Puncture/Laceration Rate) were refined so that the indicator focuses on the most serious intraoperative injuries … review and expert opinion from 13 clinical specialists in surgery, internal medicine, nephrology, trauma … when the pressure ulcer developed, due to tissue damage. … PSI 08 30-day readmission for wound infection Hospital readmission for wound infection within 30

189. The impact of dedicated medication nurses on the medication administration error rate: a randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/impact-dedicated-medication-nurses-medication-administration-error-rate-randomized-controlled
     September 24, 2010 - July 17, 2024 Early identification and evaluation of severe pressure injuries. … March 19, 2019 Detection of missed injuries in a pediatric trauma center with the addition

190. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. | PSNet
     psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
     January 06, 2018 - Review Preventing in-facility pressure ulcers as a patient safety strategy: a systematic … Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. … Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. … December 8, 2021 Pressure Injury Prevention in Hospitals Training Program. … injury policy.

191. Patient Safety Indicators at an academic veterans affairs hospital: addressing dual goals of clinical care and validity. | PSNet
     psnet.ahrq.gov/issue/patient-safety-indicators-academic-veterans-affairs-hospital-addressing-dual-goals-clinical
     August 09, 2023 - accurate data capture interventions to improve rates of the composite PSI-90 and three individual PSIs ( pressure … Postoperative PE/DVT, postoperative sepsis, and composite PSI-90 all decreased, while pressure ulcer … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … More About The Topic Hospitals Hospital Medicine Nurse Care Nosocomial Infections Pressure

192. Psi90 Factsheet Faq V2 (pdf file)
     qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ_v2.pdf
     October 05, 2016 - ) or Deep Vein Thrombosis (DVT) Rate  PSI 13 Postoperative Sepsis Rate  PSI 14 Postoperative Wound … Puncture/Laceration Rate) were refined so that the indicator focuses on the most serious intraoperative injuries … review and expert opinion from 13 clinical specialists in surgery, internal medicine, nephrology, trauma … 0.208953 -38.2% PSI 13 Postoperative Sepsis Rate 0.057308 0.216046 277.0% PSI 14 Postoperative Wound … when the pressure ulcer developed, due to tissue damage.

193. Glasgow Coma Scale for Field Triage of Trauma: A Systematic Review (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/field-triage-glascow_executive.pdf
     January 01, 2017 - ; of these approximately 2.5 million were due to trauma complications and unspecified injuries.3 Approximately … , systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medications … , systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medication … , systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medication … , systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medication

194. 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.

195. 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.

196. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867035/psn-pdf
     October 30, 2024 - treated with albuterol without improvement, which prompted the initiation of bilevel positive airway pressure … She sustained head trauma, blunt trauma of the cervical spine, right rib fractures, and a right femur … initial ED presentation, she was alert and oriented, and her vital signs were stable, with a blood pressure … We do not know if the patient’s fall at home resulted in head trauma, which may have predisposed her … case or contributed to a worse injury.

197. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866693/psn-pdf
     September 11, 2024 - Common incidents included pressure injuries, medication errors, and premature discharge.

198. References (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
     January 01, 2017 - trial with 20 patients without lung disease, requiring mechanical ventilation admitted to either a trauma … regression analysis adjusted for baseline characteristics and underlying ARDS risk factors (sepsis, trauma … concentrations of TNF-alpha and of slCAM-1; Reductions of Vt, with subsequently decreased peak airway pressures … The plateau airway pressures of group PV were lower than those groups of CV+PEEP (p=0.02) and CV+ZEEP … , such as multiple transfusions, trauma, sepsis, or high-risk surgery.

199. Declines in Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
     June 02, 2025 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse Events Pressure

200. Section 7. Tools and Resources (continued) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
     October 01, 2014 - If a skin disruption is found, the type of skin injury will need to be identified. … Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury?   … Wound care team * Wound Care Physician Directs patient care, orders tests and treatments, … medical staff, wound team, and unit staff for pressure ulcer practice Certified Wound Care