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101. 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

102. 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

103. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
     www.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

104. 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

105. Healthcare Costs | Agency for Healthcare Research and Quality
     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

106. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-factsheet.docx
     January 01, 2017 - Emerging evidence links protective tidal ventilation to decreased incidence of acute lung injury (ALI … Use at least 5 cm H2O positive end expiratory pressure (PEEP). Why wait? … not yet have ARDS and particularly those with risk factors to prevent progressive development of lung injury … Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation … What tidal volumes should be used in patients without acute lung injury?

107. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhosp-reports-slides.pptx
     November 30, 2013 - Major injury Minor injury Non-Fall-Related Injury Major injury Minor injury Musculoskeletal Joint pain … & Skin Cellulitis Edema Infected wound or decubitus Jaundice Rash Treatment Unavailable at Transferring … & Skin Injury: Fall Related Injury : Non-Fall Related Musculoskeletal Abnormal Labs or Anemia Fever/ … or Skin Fall-Related Injury Non-Fall-Related Injury Abnormal Lab Results Fever / Possible Infection … Disease Asthma Circulatory Problems Hypertension or Renal Failure Gastroenteritis Angina Pectoris Falls /Trauma

108. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
     January 01, 2022 - injuries or complications of pressure injuries present on admission (POA) was significantly higher … injuries or complications of pressure injuries present on admission (13.4% vs. 4.7%) and catheter-associated … When the individual AE rates were analyzed by sex, the AE rate for advancing pressure injuries or complications … of pressure injuries POA was significantly higher for males than females (7.2% vs. 4.9%). … Pressure Injury/Ulcer (PI) Advancing PI or Secondary Comorbidity in PI Present on Admission New

109. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
     January 01, 2022 - injuries or complications of pressure injuries present on admission (POA) was significantly higher … injuries or complications of pressure injuries present on admission (13.4% vs. 4.7%) and catheter-associated … When the individual AE rates were analyzed by sex, the AE rate for advancing pressure injuries or complications … of pressure injuries POA was significantly higher for males than females (7.2% vs. 4.9%). … Pressure Injury/Ulcer (PI) Advancing PI or Secondary Comorbidity in PI Present on Admission New

110. Table 15A: Outcome Indicators by County Demographics | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15.html
     February 01, 2023 - 8,997 6,894 8,597 6,888 Composite: ACSC Overall 22,706 18,412 21,951 18,376 Pressure … 10,186 7,869 9,760 7,859 Composite: ACSC Overall 24,978 20,372 24,196 20,327 Pressure … 4,856 4,215 4,625 4,246 Composite: ACSC Overall 14,792 13,022 14,282 13,066 Pressure … 3,483 3,293 3,410 3,308 Composite: ACSC Overall 5,671 5,408 5,482 5,469 Pressure … 7,968 6,752 7,567 6,782 Composite: ACSC Overall 20,938 18,196 19,552 18,470 Pressure

111. Appendixes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-appendix.html
     November 01, 2017 - , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … ] OR "Decubitus Ulcer" [tiab] OR "Pressure Sore" [MeSH] OR "Pressure Sore" [tiab] OR "Suspected Deep … Tissue Injury" [tiab] OR "Pressure Ulcer" [MeSH] OR "Pressure Ulcer" [tiab] OR "osteomyelitis" [MeSH] … Ostomy/wound Mgmt . 2016 Nov;62(11):30. d  Weiser TG, Semel ME, Simon AE, et al. … The cost of serious fall-related injuries at three Midwestern hospitals.

112. Indwelling Urinary Catheter Indications
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications.pptx
     April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention, due to spinal injury. … when no or little urine is seen in bladder Consider urology consultation for prostatitis and urethral trauma … Closed pressure ulcers: stage I, deep tissue injury No No, unless has chronic ISC needs Yes, if the patient … require an indwelling urinary catheter if the wound can be kept clean by other methods Use alternatives … J Wound Ostomy Continence Nurs. 2020;47(6):601-18. PMID: 33201147.

113. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
     October 01, 2014 - Remember, pressure ulcers are areas of soft tissue damage caused by pressure or pressure and shear. … 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.

114. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
     October 01, 2014 - Remember, pressure ulcers are areas of soft tissue damage caused by pressure or pressure and shear. … 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.

115. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
     April 01, 2025 - Preventing Falls and Reducing Injury from Falls https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries … Pressure Ulcer Reduction 1. … Pressure Injury Training Modules https://npiap.com/page/TrainingModules The NPIAP Pressure Injury … injuries. 3. … Ulcer Data Collection Tool Instructions Preventing Falls and Reducing Injury from Falls Quality Assurance

116. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
     January 01, 2017 - Patients Adverse Events4 9 patients had 14 adverse events (<1% of activities) Falls to knees without injury … (5) Systolic blood pressure <90 mmHg (4) Oxygen saturation <80% (3) Nasal feeding tube removal (1) … Systolic blood pressure >200 mmHg (1) No extubations No patients required added therapy or increased … sessions (i.e., 6 per 1,000 PT treatment) 80% of events were transient physiological (heart rate, blood pressure … Safety Program for Mechanically Ventilated Patients 5-Year Sustainability of Time to PT Postacute Lung Injury

117. Overuse of Imaging for the Evaluation of Children with Post-Traumatic Headache (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-fullreport.pdf
     December 17, 2019 - , seizure associated with trauma, loss of consciousness associated with trauma, repeated vomiting, documented … These risks include dental trauma; airway edema (swelling of the windpipe); vocal cord spasm or injury … Was there documentation of increased intracranial pressure? … The sensitivity of claims for identification of indicators of increased intracranial pressure was 8.1 … in a non-trauma center.

118. C1 Prioritization Worksheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
     June 02, 2025 - purchasing • Sentinel event • Publicly reported • Public perception • Marketing • Competitive pressure … Rate on scale of 10 (agree/high) to 0 (disagree/low) PSI 14 Postoperative Wound … Dehiscence PSI 15 Accidental Puncture or Laceration 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

119. Overuse of Computed Tomography Scans for the Evaluation of Children with Atraumatic Headache: Technical Specifications (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0206-technicalspecs.pdf
     May 01, 2016 - Exclusions • Denominator/Numerator Exclusions o Trauma-related headache or pain (Table … IMG3) on the day of or within 7 days prior to imaging o Head trauma or suspected abuse/neglect (Table … 339.43 Other complicated 339.44 OTHER Post- traumatic headache 339.2x Acute pain due to trauma … excision of foreign body from brain 61570 Craniectomy or craniotomy; with treatment of penetrating wound … 852.x Other/unspecified intracranial hemorrhage following injury 853.x Intracranial injury of other

120. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
     December 01, 2017 - Few days later, he develops fever and his blood pressure drops. … Keeps patients from having to get up to urinate, protecting them from injury. … Trauma) Admitting service (e.g. … Is the patient incontinent with open sacral or perineal wounds? … Protocolized care for trauma Incontinence without open sacral or perineal wounds Pre-operative