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121. Appendix B11: Fall Interventions Plan | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6.html
     February 01, 2023 - Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions __ Low blood pressure … __ Behavior management strategies __ Increase assistance and surveillance    __ Position or pressure … _ Increase activities involvement    __ Other ___________________________ __ Reduce risk of injury

122. Beyond Nursing Quality Measurement: The Nation’s First Regional Nursing Virtual Dashboard (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
     January 01, 2021 - Patient outcome variables Patient falls and injury falls • Patient falls/1,000 patient days. … • Injury falls/1,000 patient days. … • Percent of patients with suspected deep tissue injury. 3 Table 1. … • Percent of patients with hospital-acquired suspected deep tissue injury. … ulcers stages III and IV, as well as fall and injury fall incidence and rates.

123. Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care (pdf file)
     www.ahrq.gov/downloads/pub/advances2/vol1/advances-hook_25.pdf
     February 26, 2008 - , impaired physical mobility, accidental injuries, patient safety, safety management, injury control … Minor: Resulted in application of a dressing, ice, cleaning of a wound, limb elevation, or topical … Blood pressure changes on upright tilting predict falls in older people. … Complications of preinjury warfarin use in the trauma patient. J Trauma 2003; 54: 842-847. 36. … Minor head trauma in anticoagulated patients. Acad Emerg Med 1999; 6: 121-124. 38.

124. Using a Computerized Fall Risk Assessment Process to Tailor Interventions in Acute Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Hook_25.pdf
     February 26, 2008 - , impaired physical mobility, accidental injuries, patient safety, safety management, injury control … Minor: Resulted in application of a dressing, ice, cleaning of a wound, limb elevation, or topical … Blood pressure changes on upright tilting predict falls in older people. … Complications of preinjury warfarin use in the trauma patient. J Trauma 2003; 54: 842-847. 36. … Minor head trauma in anticoagulated patients. Acad Emerg Med 1999; 6: 121-124. 38.

125. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/hacrate2013-refs.html
     October 01, 2015 - Injury From Falls Barrett JA, Bradshaw M, Hutchinson K, et al. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers Agency for Healthcare Research and Quality.

126. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ref.html
     December 01, 2014 - Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers Agency for Healthcare Research and Quality. … Eliminating facility-acquired pressure ulcers at Ascension Health .

127. Intramuscular Injections – Best Practices for Safe Vaccine Administration in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/intramuscular-injections.pdf
     June 01, 2021 - intramuscular (IM) administration is important to make sure the vaccine does its job and to avoid shoulder injury … and Health Administration (OSHA) regulations do not require you to wear gloves unless you have open wounds … Apply gentle pressure to the injection site for several seconds or longer to minimize bleeding using … For residents who take anticoagulation medications, gentle pressure may need to be applied longer to … pre-filled autoinjector (at least three doses) • H1 antihistamine (e.g., diphenhydramine/Benadryl) • Blood pressure

128. Appendix C8: Fall Interventions Plan Sample | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt8.html
     December 01, 2017 - Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions ___ Low blood pressure … Behavior management strategies _X_ Increase assistance and surveillance    _X_ Position or pressure … Increase activities involvement    ___ Other ___________________________ _X_ Reduce risk of injury

129. Documentation and Coding for Patient Safety Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
     March 15, 2016 - PDI 02 Pressure Ulcer Rate (stage III, IV, Unstageable) Diagnosis and site of pressure ulcer must … PSI 18, PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without … X PDI 11 Postoperative Wound Dehiscence Rate X Depth of the wound dehiscence: external/superficial … X PSI 14 Postoperative Wound Dehiscence X Depth of the wound dehiscence: external/superficial vs … PSI 18 PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without

130. Session 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess2.html
     October 01, 2014 - Additional Tools and Resources Limiting Falls that Cause Injury Residents in long-term … However, what we can do is eliminate needless falls and limit the injuries from falls that do occur. … Things about the equipment or care plan (e.g., monitor blood pressure frequently). … Things about equipment or the care plan, including: More frequent blood pressure monitoring. … Relationship between physical restraint removal and falls and injuries among nursing home residents.

131. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
     December 01, 2012 - 9,257 6,892 Composite: ACSC Overall 17,570 24,934 20,620 17,662 23,518 18,337 Pressure … 10,435 7,884 Composite: ACSC Overall 19,406 27,524 22,656 19,821 25,958 20,278 Pressure … 5,382 4,110 Composite: ACSC Overall 12,450 16,541 14,919 11,150 15,491 12,897 Pressure … 3,777 3,248 Composite: ACSC Overall 5,094 6,963 6,484 4,695 6,310 5,297 Pressure … 8,215 6,780 Composite: ACSC Overall 17,579 23,121 20,378 17,055 21,295 18,297 Pressure

132. Examples of Patient Harm Related to Invasive Devices | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
     October 01, 2015 - Teamwork and Communication Definitions and Tools Several examples of severe patient injury … Paraplegia (inability to walk) Ultimately, the patient underwent back surgery to decompress the pressure … The virulent organism caused a severe infection and irreversible injury to the patient. … She was found to have a fever of 102 °F, and her blood pressure dropped to 90 systolic.

133. C1 Prioritization Matrix (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
     June 02, 2025 - Patient Safety PSI 03 Pressure Ulcer   1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y PSI 06 Iatrogenic … 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y Obstetric PSI 17 Birth Trauma-Injury … to Neonate   0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y PSI 18 Obstetric Trauma-Vaginal Delivery … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

134. Long-term Care Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
     November 01, 2021 - Nursing Homes: On-Time Prevention End of Life Care Home and Community-based Services Falls and Injury … Long-Term Care Facilities Multiple Chronic Conditions Omissions of Care in Nursing Homes Pressure

135. AHRQ Patient Safety Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/PS-tools-2024.pdf
     January 01, 2024 - Web: ahrq.gov/goinghomeguide/ Pressure Ulcers Preventing Pressure Ulcers: A Toolkit for Improving … Web: ahrq.gov/pressureulcertoolkit The Pressure Injury Prevention in Hospitals Training Program supports … the training of hospital staff on how to implement AHRQ’s Preventing Pressure Ulcers in Hospitals … injury prevention. … approaches to design that target six areas of safety: infections, falls, medication errors, security, injuries

136. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/062-protocol-training-decolonization-with-chg.pptx
     October 01, 2024 - Superficial pressure injuries (stages 1 and 2) CHG should also be applied over sutured or stapled wounds … Clean wound carefully with CHG. … Apply CHG with firm pressure, unless the wound is over a bony prominence. … Using the CHG on superficial wounds, and stage 1 and 2 pressure injuries. … Refer to the slides on Wound Care.

137. Electronic Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/ereports.html
     December 01, 2017 - This report is helpful for nursing home staff and wound nurses to promote early identification of pressure … These details are available at the time the pressure ulcer is being assessed during wound rounds or during … Information that displays on the Weekly Pressure Ulcer Treatment Summary Report, the Weekly Wound Rounds … Uses DON or ADON, Nurse Manager, Wound Nurse, QI Director Root Cause Analysis for New Pressure … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance

138. Outcomes | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/outcomes.html
     Hospital Reduces Emergency Wait Time, Adverse Events Using AHRQ Tools Connecticut Hospital Reduces Pressure … Injuries Using AHRQ Toolkit Georgetown University Family Nurse Practitioner Program Trains Hundreds

139. Final Progress Report: Effects of Patient Turnover on Nursing Care and Patient Outcomes in Acute Care Hospital Settings (pdf file)
     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

140. Background for AHRQ Quality Indicators
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pptx
     October 01, 2015 - in October 2015: Addition of information relevant to ambulatory and managed care encounters Expanded injury … Postoperative pulmonary embolism or deep vein thrombosis   PSI 13 Postoperative sepsis   PSI 14 Postoperative wound … dehiscence PSI 15 Accidental puncture or laceration PSI 16 Transfusion reaction PSI 17 Birth trauma-injury … to neonate PSI 18 Obstetric trauma-vaginal delivery with instrument PSI 19 Obstetric trauma-vaginal … PDI 09 Postoperative Respiratory Failure Rate PDI 10 Postoperative Sepsis Rate PDI 11 Postoperative Wound