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cahps.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.
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cahps.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
October 01, 2014 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and … 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.
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cahps.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.
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_tools.docx
January 01, 2012 - · Identify all visible injuries and initiate first aid; for example, cover wounds.
· Assist patient … hydration).
· Clean and dress any wounds … · Identify all visible injuries and initiate first aid; for example, cover wounds. … · Clean and dress any wounds.
· Arrange medical review. … Describe injuries; check all that apply
Injury
Yes
No
Site of Injury
Abrasion/bruise/laceration
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cahps.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/prp/prp-wound-care.pdf
September 17, 2020 - formation include diabetes, pressure
injuries, and venous or arterial diseases. … formation include diabetes, pressure
injuries, and venous or arterial diseases. … Haesler E, ed Prevention and Treatment of
Pressure Ulcers/Injuries. … EPUAP/NPIAP/PPPIA: European Pressure
Ulcer Advisory Panel, National Pressure
Injury Advisory Panel … and Pan Pacific
Pressure Injury Alliance; 2019.
32
Abbreviations and Acronyms
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cahps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/index.html
September 01, 2018 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Module 3 Tools ( MS Word , 268 KB)
Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … Network Webinars
Related AHRQ Resources
Preventing Falls in Hospitals Toolkit
Pressure … Injury Prevention in Hospitals Training Program
Page last reviewed September
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cahps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/webinars/index.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Assessment Tools in Care Planning (25 min) ( PDF of the Slides , 2.16 MB)
Measuring Fall and Fall-Related Injury … Network Webinars
Creating Control Charts To Interpret Fall Data (62 min)
Critical Thinking for Fall Injury … Prevention Care Planning (61 min)
Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
July 01, 2016 - 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
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cahps.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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cahps.ahrq.gov/patient-safety/settings/hospital/index.html
March 01, 2024 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … pressure ulcer prevention practices through an interdisciplinary approach to care. … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. … injury prevention.
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cahps.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … If unsure whether it is a pressure ulcer, get help from the wound care nurse or another experienced clinician … Typically, this comprehensive evaluation is performed by an "outside" expert such as a wound nurse or … Therefore, consider performing a comprehensive skin assessment every 3 months with a wound care nurse … Pressure ulcers may take several days to develop after a severe pressure injury.
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 05, 2016 - Best practices forms exist for the following 14 PSIs:
• PSI 03 Pressure Ulcer Rate
• PSI 05 Retained … Pulmonary Embolism or Deep Vein Thrombosis Rate
• PSI 13 Postoperative Sepsis Rate
• PSI 14 Postoperative Wound … 03 Neonatal Blood Stream Infection Rate
• PDI 01 Accidental Puncture or Laceration Rate
• PDI 02 Pressure … Postoperative Respiratory Failure Rate
• PDI 10 Postoperative Sepsis Rate
• PDI 11 Postoperative Wound … • PSI 17 Birth Trauma Rate―Injury to Neonate: The existing literature on birth trauma
and injury
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - 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
21.7 23.5 22.7 23.0 6% 17.4
Surgical Site
Infections
2.5 2.5 2.5 … Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs for 17 procedures w/CDC SCIP … Ulcers/Pressure
Injuries
Surgical
Site
Infection
NHSN SSIs for 17
procedures
w/CDC SCIP+5
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cahps.ahrq.gov/research/findings/studies/index.html?page=1
January 01, 2024 - and Wounds
(207)
Inpatient Care
(220)
Intensive Care Unit (ICU)
(264)
Kidney Disease and … Outcome measures included hypertension, systolic blood pressure >130 mmHG, and hyperglycemia. … center (NTC) and were diagnosed with a traumatic injury with an injury severity score of greater than … , major chest injury, and presentation at a teaching hospital. … , Injuries and Wounds
Cron DC , Braun HJ , Ascher NL Sex-based disparities in access to
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
February 10, 2014 - The vendor determines the methodology to assign unique IDs to resident wounds. … :
· 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Most Recent Assess Ulcer Stage … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Ulcer Origin
Wound Assessment … :
Stage 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Ulcer Origin
Wound Assessment … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI).
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cahps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html
January 01, 2013 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Have possible spinal injuries.
Have lower extremity or pelvic fractures. … Blood pressure cuff of correct size for the patient. … Check sitting blood pressure and pulse. … Support the forearm at heart level when taking the blood pressures to prevent inaccurate measurement.
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cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
April 08, 2016 - 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
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cahps.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
November 01, 2017 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Adverse Events
Pressure Ulcer Prevention .
Pressure Ulcer Healing .
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cahps.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … None or no injury: The patient is free of injuries (no signs or symptoms) resulting from a fall … Death: The patient died as a result of injuries sustained from the fall (not from physiologic events … Slide 13: NDNQI Definitions of Fall Injury
None: No injury
Minor: Resulted in bruise, abrasion
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cahps.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html
May 01, 2016 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Pressure ulcers remain a serious problem in nursing homes despite regulatory and market approaches to … Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer … Median annual nursing home pressure ulcer prevalence was 7.5 percent in 2009, with associated costs of … Materials
Self-Assessment Worksheet for Pressure Ulcer Prevention .