-
psnet.ahrq.gov/node/60027/psn-pdf
January 01, 2021 - Improvements in medication errors and hospital-
acquired pressure injuries were observed, but employee
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psnet.ahrq.gov/node/843054/psn-pdf
January 25, 2023 - The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/Xm5_jgUrXXGAJe8WJh_9KK
June 01, 2024 - initial assessment of modifiable risk factors for falls (eg, balance, gait, vision,
postural blood pressure … Falls are the leading cause of injury-related morbidity and mortality among older adults in the US. … adults 65 years or older reported at least 1 fall in the past year and 10.2% reported a fall-
related injury … In 2021, 38,742 deaths resulted from fall-related injuries. … • The CDC’s STEADI (Stopping Elderly Accidents, Death, and Injuries) initiative helps reduce fall
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - LMA use have been reported.(6) The
most common complications include aspiration and unintended local trauma … with
LMAs and high peak inspiratory pressures, allowing for inspired gases to insufflate the stomach … LMA use can also lead to injuries secondary to high cuff pressure and volume during prolonged
procedures … These increased intra-cuff pressures can cause a significant damage to surrounding tissues. … the pyriform sinus, which is where the recurrent laryngeal nerve enters, rendering it vulnerable to injury
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/depression-brain-injury_research-protocol.pdf
December 09, 2009 - Trauma[mh] OR TBI[tiab] OR head injuries[tiab] OR head
injury[tiab] OR traumatic brain injury[tiab] … brain injury" or "traumatic
brain injuries" OR "craniocerebral trauma" or neurotrauma or "brain trauma … brain injury" or
"traumatic head injury" or "traumatic brain injuries" or "traumatic head
injuries … injuries" OR "head injury" OR
"head trauma" OR "brain trauma"
http://www.effectivehealthcare.ahrq.gov … brain injuries" OR "head
trauma" OR "craniocerebral trauma" OR "brain injury" OR "brain injuries" )
-
hcup-us.ahrq.gov/reports/statbriefs/sb3.pdf
April 01, 2006 - t
hospit
treatm
were f
respon
admis
five m
condit
pneum
infecti
itis, an
Amon
princip
comm
includ
injury … ean charge for hospital
principally for pressures
was $37,800, but charges
by payer; e.g., the aver … percent), paralysis (27.4 percent), senility (22.7 percent), malnutrition (17.8 percent),
spinal cord injury … Paralysis, spinal cord injury, and
substance abuse were prominent among younger patients, while malnutrition … 21.7
36.6
47.6
10.5
74.8
13.913.2
43.1
14.1
8.76.7
0
20
40
60
80
Paralysis Spinal cord
injury
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar5_pu_riskassesst-tools.pdf
January 01, 2012 - Adv Skin Wound
Care 2001;14(3):133-7.
38
Resources
• John A. … Injury Alliance. … Adv Skin Wound Care 2012;
25(4):167-88.
• Rapp MP, Bergstrom N, Padhye NC. … Adv Skin Wound
Care 2009;22(11):506-13.
• Shanks HT, Kleinhelter P, Baker J. … Adv Skin Wound Care 2011;24(12):562-70.
39
http://www.hartfordign.org/practice/try_this/
Using Pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar3_pu_staffroles.pdf
January 01, 2014 - Program.
8
Wound Care Team: Roles and Duties
• Serve as your hospital’s content experts on
pressure … ulcer
injury prevention … Nursing 2014 survey results: Wound care and
prevention. … Advances in Skin and Wound Care. 2010; 23(3):120-31.
• Levine J, et al. … Advances in Skin and Wound Care. 2007;
20(1):34-38.
37
Staff Roles and Training forYour Pressure
-
hcup-us.ahrq.gov/reports/statbriefs/sb207-Sports-Hospital-Emergency-Department-2013.jsp
July 01, 2016 - wound: 12; other diagnosis: 6; intracranial injury: 5. … Other common, specific types of injuries included open wounds (12 percent) and intracranial injuries … Bicycle riding: sprain: 11; fracture: 22; superficial injury: 26; open wound: 19; intracranial injury … Basketball: sprain: 40; fracture: 16; superficial injury: 11; open wound: 10; intracranial injury: 3; … Soccer: sprain: 31; other injury: 21; superficial injury: 15; open wound: 6; intracranial injury: 6;
-
psnet.ahrq.gov/issue/care-home-safety-incidents-and-safeguarding-reports-relating-hospital-care-home-transitions
July 17, 2024 - Common incidents included pressure injuries, medication errors , and premature discharge. … Long-Term Care
Geriatrics
Discontinuities, Gaps, and Hand-Off Problems
Medical Complications
Pressure
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psnet.ahrq.gov/issue/missed-nursing-care-emergency-departments-scoping-review
November 03, 2021 - include overcrowding and patients with complex care needs, which may result in medication errors, pressure … injuries, or patient deterioration. … More About The Topic
Emergency Departments
Emergency Nursing
Administration Errors
Pressure
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psnet.ahrq.gov/issue/preventing-newborn-falls-and-drops
October 10, 2018 - February 21, 2018
Early identification and evaluation of severe pressure injuries. … December 8, 2010
National safety effort targets perinatal injuries.
-
psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
August 24, 2022 - Emerging Classic
Assessment of nursing home reporting of major injury … Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare … This study compared falls with injury data self-reported by nursing homes against those identified in … Download Citation
Related Resources From the Same Author(s)
Accuracy of pressure … September 14, 2022
Accuracy of pressure ulcer events in US nursing home ratings.
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psnet.ahrq.gov/node/60551/psn-pdf
January 01, 2021 - The authors discuss major CMS payment policy changes and their intersection
with the PSI; except for pressure … injuries, the implementation of payment policy reforms did not precede the
decline trends in PSI rates
-
psnet.ahrq.gov/node/836964/psn-pdf
April 20, 2022 - The most common
preventable events were medication events, pressure injuries, and healthcare-associated
-
psnet.ahrq.gov/node/50775/psn-pdf
January 01, 2021 - reports involved
interunit/department/team transfers and the majority (69%) of incidents were related to pressure … injuries,
falls, medication, and documentation errors.
-
psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - wound. … Trauma-induced coagulopathy: what you need to know. J Trauma Acute Care Surg. 2024;96(2):179-185. … Vascular injury and complication in neurosurgical spine surgery. … Craniomaxillofac Trauma Reconstr. 2013;6(4):257-266. … Hetastarch during initial resuscitation from trauma. J Trauma. 2011;70(5 Suppl):S19-S21.
-
www.ahrq.gov/sites/default/files/2024-09/park-report.pdf
January 01, 2024 - • Hypothesis 4: Higher unit patient turnover will be associated with more pressure injuries
and falls … NDNQI
Unit-acquired
pressure injury Unit
Number of patients who acquired a pressure ulcer after
arrival … , Poisson regression modeling for falls and injury falls and logistic
regression modeling for pressure … falls, and pressure injuries, as reported by NDNQI. … Unit-level patient
outcomes of falls, injury falls, and pressure injuries were not statistically significant
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
June 02, 2025 - 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
-
www.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.