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qualityindicators.ahrq.gov/Downloads/Resources/Publications/2012/Appendix_1A_Details_of_literature_review.pdf
January 01, 2012 - Inflicted by Others 10
Medication Errors 17
Pressure Ulcer 20
Accidental Injuries Potentially … for location, depth and
stage, size, and wound bed (e.g., necrotic tissue, exudate, wound edges for … "Spinal cord injury and pressure ulcers." Nurs Clin North Am 40(2): 337-347. … Other Injuries
• One review examined prevention of injury in people with intellectual disabilities. … Potentially Due to Neglect
“wounds and injuries”[MeSH] OR “accidental injury”[MeSH]
“accidental falls
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - However, it is associated with several positioning injuries. … In rare circumstances, significant hypoperfusion with ischemic injury to the calf muscles may result … Pressures above 30 mm Hg are worrisome, but the diagnosis can be easily missed if the pressure is measured … Early evaluation and fasciotomy by an orthopedic or trauma surgeon are key to preventing permanent injury … Int Wound J . 2008;5(2):315-328. [ Free full text ] Matsen FA 3rd.
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psnet.ahrq.gov/issue/preventing-patient-positioning-injuries-nonoperating-room-setting
November 21, 2012 - Commentary
Preventing patient positioning injuries in the nonoperating room setting … Preventing patient positioning injuries in the nonoperating room setting. … Hospital-acquired pressure injuries are considered a never event . … This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA … Preventing patient positioning injuries in the nonoperating room setting.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 5 Tools
Action Plan Tool … to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices
Tool 5C: Assessing Comprehensive … Assessment
Tool 5D: Assessing Standardized Risk Assessment
Tool 5E: Assessing Care Planning
AHRQ Pressure … stakeholders and staff
Root cause analysis is conducted for each fall with at least moderate level of injury … admission nursing assessment, subsequent nursing progress notes, or any notes specifically documenting pressure
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psnet.ahrq.gov/node/74253/psn-pdf
January 12, 2022 - Injuries
The risk of pressure injuries of the skin and soft tissue has increased during the pandemic … injuries. … the risk of pressure injury
among COVID-19 patients.7
Infections
Among COVID-19 patients in particular … Injury Advisory Panel, and recommendations developed by researchers on the
prevention of pressure injuries … Medical device-related pressure injuries during the COVID-19 pandemic.
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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - Other important factors are
nursing-sensitive events, which include things like pressure injuries and … For example, with pressure injuries, wetness
in the bed dramatically increases the risk that somebody … will develop a dangerous pressure injury. … Some of these sensors are expensive, but pressure injuries are extremely expensive. … will take a look at your pressure injuries practices and take steps to improve those.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/065-dec-staff-faqs-decolonization.docx
October 01, 2024 - Be especially thorough if there are any nearby wounds, pressure injuries, or breaks in the skin. … Use the CHG on superficial wounds and stage 1 and 2 pressure injuries. … Wound Cleaning
For what types of wounds is CHG safe? … CHG can be applied to any superficial wounds, including stage 1 and 2 pressure injuries, friable skin … and stage 1 and 2 pressure injuries.
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Her wounds led to significant blood loss. … arterial blood pressure.23 Elevated
compartment pressure leads initially to venous congestion, then … transferred to the OR for surgical exploration, debridement, and possible closure of
her traumatic wounds … Injury. 2017;48:S22–S25. … Injury. 1994;25(6):379–81. [Free full text]
31. Günal I, Köse N, Gürer D.
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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - infection and subsequent partial dehiscence due to inadequate wound care
• Wound infection of below … 2 nasal pressure ulcer associated with face mask
• Deep tissue injuries related to ace wraps
• New stage … 2 sacral pressure ulcer
• Progression of stage 2 to stage 3 sacral pressure ulcer
• Sacral pressure … injury of sacral area
• Suspected deep tissue injury of the sacrum
• Worsening pressure ulcer of sacrum … Bleeding not directly associated with anticoagulants
• Gross hematuria due to trauma from urinary catheter
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
June 02, 2025 - (Tool 2C)
Present the assessment of current pressure injury prevention policies and procedures. … Link the Pressure Injury Prevention Program with quality improvement. … Injury Implementation Team
Wound Care Team
Unit Team
12
Collaborative Relationships
Unit-Based Team … Current Pressure Injury Processes
Understand current processes in patient care units. … Let’s look at completed Tool 2D now.
19
Assess Pressure Injury Screening Practices
Tool 2E
20
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 3 Tools
3A: Pressure Ulcer … 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? … A wound/ostomy nurse consult revealed he has a slightly pink coccyx area (base of spinal column).
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pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - and agitation secondary to benzodiazepine led
to patient pulling urinary catheter with resultant injury … brace
• Skin excoriation on buttocks
Fall associated with patient care
• Fall from bed with minor injuries … (elbow, knees, and small skin tear)
Device trauma or malfunction
• Clotted arteriovenous shunt (dialysis … access device)
• Trauma due to multiple failed Foley catheter insertions
Edema or volume overload
• … erythema on right thigh
Surgical Site Infection (SSI)
• Superficial infection that developed on existing wound
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides2.html
October 01, 2017 - (Tool 2C)
Present the assessment of current pressure injury prevention policies and procedures. … Slide 5: Expected Outcomes
Begin to write a draft Pressure Injury Prevention Action Plan, tailored … Members who influence the areas involved in pressure injury prevention. … Slide 12: Collaboration
Pressure Injury Implementation Team.
Wound Care Team. … Wound Care Team: Interdisciplinary group of experts who provide day-to-day care of skin and wound needs
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
December 01, 2017 - Use Low Blood Pressure Precautions
Slide 1. … Paralysis, tremors
Loss of joint mobility, contractures
Lower extremity weakness
Drop in blood pressure … Physical Restraints
Physical restraints increase the likelihood of serious injury resulting from … Consequences of Falls
Serious injury such as hip fracture
Increased risk of death associated … Use Low Blood Pressure Precautions
For residents with low blood pressure:
Sit on edge of bed
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - shock or from traumatic brain injury … , or through skin with overlying infection or
burn injury … mean arterial blood pressure … unreliable and rarely used in pediatrics
due to differences in normal resting compartment pressures … transferred to the OR
for surgical exploration, debridement, and possible closure of her
traumatic wounds
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www.ahrq.gov/topics/healthcare-costs.html
Patient Falls by 21 Percent
Chartbook on Care Affordability
Connecticut Hospital Reduces Pressure … Injuries Using AHRQ Toolkit
Estimating the Costs of Primary Care Transformation: A Practical Guide
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - due to procedures,
as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries
increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/Pressure
Injuries
Obstetric Adverse Events
Falls
Clostridioides difficile
Infections
Central … Ulcers/
Pressure Injuries
21.7 23.5 22.7 23.0 6%
Surgical Site Infections 2.5 2.5 2.5 2.7 8% … Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs for 17 procedures w/CDC SCIP
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - o Wound edges. … -
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-
injury/
Staff … Washington, DC: National Pressure Ulcer
5 Tool D.4a
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury
-
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apd.html
October 01, 2017 - Pressure Injury Prevention Program Implementation Guide
Appendix D. … Injury Prevention Program Implementation Guide
Overview
Get Ready
Pressure Injury Prevention Program … Hospital Practice Insights: Challenges and Solutions
Production Agenda: Pressure Injury … Injury Rates and Pressure Injury Prevention Practices .
25
Measuring pressure injury … Injury Rates and Pressure Injury Prevention Practices
3:50–3:55
5
Closing
Evaluation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - hospital mattress.7,8-11
o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in
hospitalised patients. Int Wound J 2010;7:358-65.
7.