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321. The mindful path to nursing accuracy: a quasi-experimental study on minimizing medication administration errors. | PSNet
     psnet.ahrq.gov/issue/mindful-path-nursing-accuracy-quasi-experimental-study-minimizing-medication-administration
     March 03, 2019 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … August 26, 2020 Organisational strategies to implement hospital pressure ulcer prevention

322. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33597/psn-pdf
     April 10, 2024 - care hospitals, including the ability to care for patients requiring mechanical ventilation, complex wound … Inpatient rehabilitation facilities (IRFs) care for patients recovering from surgery, trauma, or an … evaluation by a physician but do require services such as intensive nursing, physical therapy, or wound … injuries) during their stay, half of which were preventable. … injuries, and falls).

323. Instruments and warning signs for identifying and evaluating the frequency of adverse events in intermediate and long-term care centres: a narrative systematic review. | PSNet
     psnet.ahrq.gov/issue/instruments-and-warning-signs-identifying-and-evaluating-frequency-adverse-events
     July 20, 2022 - Common adverse events impacting this population include adverse drug events, delirium , malnutrition, pressure … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

324. Applying HFMEA to prevent chemotherapy errors. | PSNet
     psnet.ahrq.gov/issue/applying-hfmea-prevent-chemotherapy-errors
     September 27, 2017 - Citation Related Resources From the Same Author(s) Surgeon commitment to trauma … care decreases missed injuries. … March 9, 2009 System approach to prevent common bile duct injury and enhance performance … May 22, 2013 Interactive effects of nurse-experienced time pressure and burnout on patient

325. PMCoE PICU Expert Work Group and Leadership Team Roster (pdf file)
     www.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

326. Section 6-B, PMCoE PICU Expert Workgroup and Leadership Team Roster (pdf file)
     www.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

327. Section 6-B, Expert Workgroup Roster and Materials (pdf file)
     www.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

328. Puh-Assessment (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
     June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing On-Time Pressure Ulcer Assessment … The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool … 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 3 Stage 4 Unstageable Suspected Deep Tissue Injury

329. Too Hot For Comfort | PSNet
     psnet.ahrq.gov/web-mm/too-hot-comfort
     May 19, 2015 - Commonly used agents that cause severe extravasation injuries include antineoplastic, inotropic, or osmotically … Use to Promote Wound Healing In contrast, the wound healing literature generally supports the use … Treating chronic and acute wounds with warming: review of the science and practice implications. … Local heat increases blood flow and oxygen tension in wounds. Arch Surg. 1987;122:221-225. … March 5, 2025 WebM&M Cases Under Pressure: Tracheostomy

330. Statistical Brief #130
     hcup-us.ahrq.gov/reports/statbriefs/sb130.jsp
     May 01, 2012 - Introduction All-terrain vehicles (ATVs) are small open motorized vehicles designed with large low-pressure … ED visits for ATV injuries were more likely to occur on a weekend than the total of other injury-related … Compared with all injury related visits, those for ATV injuries were more likely to be covered by private … Case definition The External Cause of Injury codes (E-codes) used to define ATV-related injuries were … Journal of Trauma-Injury Infection and Critical Care 69(6): 1344-1349. 5 Aitken, M. E., C. J.

331. Low Tidal Volume Ventilation Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
     January 01, 2017 - (so-called ZEEP)6-15 and limiting plateau pressures to < 30 cm/H2O (as compared with 10–12 mL/kg and … to be beneficial in patients at risk for ARDS, such as those with sepsis, pneumonia, or traumatic injuries … tidal volumes in the 6–8 mL/kg PBW range along with the avoidance of ZEEP6-13,24 and limiting plateau pressures … admitted to the ICU already have risk factors for ARDS, such as pneumonia, sepsis, noncardiogenic shock, trauma … Tidal volume and plateau pressure use for acute lung injury from 2000 to present: A systematic literature

332. Puh-Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
     June 02, 2025 - The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment … 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. … to <50% wound covered 5= <25% wound covered Pain Pressure Ulcer Site Pain Select … Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Suspected Deep Tissue Injury

333. Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE. | PSNet
     psnet.ahrq.gov/issue/contributing-factors-pediatric-ambulatory-diagnostic-process-errors-project-redde
     November 30, 2022 - Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and … included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure … August 9, 2011 Delayed or missed diagnosis of cervical spine injuries.

334. A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals. | PSNet
     psnet.ahrq.gov/issue/comprehensive-program-reduce-rates-hospital-acquired-pressure-ulcers-system-community
     May 12, 2021 - Study A comprehensive program to reduce rates of hospital-acquired pressure ulcers … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … This implementation study sought to reduce incidence of pressure ulcers in hospitalized patients using … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … injury policy.

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33561/psn-pdf
     September 15, 2024 - , while being cared for in a healthcare setting Care management events Patient death or serious injury … associated with unsafe administration of blood products Maternal death or serious injury associated … of a neonate associated with labor or delivery in a low-risk pregnancy Patient death or serious injury … associated with a fall while being cared for in a healthcare setting Any stage 3, stage 4, and unstageable pressure … Because Never Events are devastating and preventable, health care organizations are under increasing pressure

336. ChartBook On Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pdf
     March 04, 2016 - Achievable Benchmark: 2.2%  Importance: Nursing home residents who experience falls resulting in major injuries … are at higher risk of death and disability, as well as emotional trauma that can affect functional … The home health team should regularly change wound dressing and teach the patient about wound care … Only Insignificant Injury Temporary Injury Permanent, Minor Injury Permanent, Significant Injury … Only Insignificant Injury Temporary Injury Permanent, Minor Injury Permanent, Significant Injury

337. 4 Tk2 T1-Medical Care Referral Form Word Doc For Html Only (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form_Word_doc_for_html_only.doc
     June 02, 2025 - including recent fever pattern and change in recent/current health status: CURRENT VITAL SIGNS Blood pressure … Suspected minor injury Yes No ? Suspected serious injury Yes No ? … 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 ?

338. 056-Nursing-Protocol-Bathing-Cloths (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/056-nursing-protocol-bathing-cloths.docx
     October 01, 2024 - CHG is also safe for superficial wounds, including stage 1 and stage 2 pressure injuries. 7.

339. 057-Nursing-Protocol-Bathing-Liquid (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/057-nursing-protocol-bathing-liquid.docx
     October 01, 2024 - CHG is also safe for superficial wounds, including stage 1 and stage 2 pressure injuries. 12.

340. AHRQ QI List of Indicators (pdf file)
     qualityindicators.ahrq.gov/Downloads/Modules/V2023/AHRQ_QI_Indicators_List.pdf
     October 01, 2023 - • PSI 02 - Death Rate in Low-Mortality Diagnosis Related Groups (DRGs) • PSI 03- Pressure … Fracture Rate • PSI 09- Postoperative Hemorrhage or Hematoma Rate • PSI 10- Postoperative Acute Kidney Injury … or Deep Vein Thrombosis (PE/DVT) Rate • PSI 13- Postoperative Sepsis Rate • PSI 14 - Postoperative Wound … Rate - Injury to Neonate • PSI 18 - Obstetric Trauma Rate - Vaginal Delivery with Instrument • PSI … 19- Obstetric Trauma Rate - Vaginal Delivery without Instrument • PSI 90- Patient Safety and Adverse