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141. Eliminating Preventable Harms During Pediatric Intubation | Agency for Healthcare Research and Quality
     www.ahrq.gov/funding/grantee-profiles/grtprofile-nishisaki.html
     July 01, 2025 - Advanced Education and Innovation, Children’s Hospital of Philadelphia Chair, Pediatric Acute Lung Injury … experiencing respiratory failure, which is caused by various conditions, including pneumonia, asthma attacks, injuries … in five children who undergo the procedure face complications, including breathing issues, low blood pressure … Nishisaki also serves as Chair of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

142. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

143. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
     May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate poisoning, … expansion exercises with children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory failure in children: a concise review

144. Putoolssect7 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
     February 16, 2011 - Pressure ulcers are sterile wounds. 36. … Pressure ulcers are sterile wounds. False 36. … If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … unit staff for pressure ulcer practice Certified Wound Care Nurse · Assesses wounds, does complex

145. On-Time Pressure Ulcer Healing: Introduction to Pressure Ulcer Healing Reports Facilitator Training Instructor's Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/erepguide.html
     December 01, 2016 - Pressure Ulcers at Risk for Delayed Healing. Weekly Wound Rounds Report. … home chains, and wound centers. … Injury Alliance. … The wound nurse, wound physician, and other disciplines attending wound rounds can see quickly which … If the pressure ulcer shows signs of delayed healing, as recorded on the wound assessment based on the

146. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.docx
     March 01, 2017 - . · Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral … wounds for selected residents with urinary incontinence. · To improve comfort for end-of-life care, … Management of the neurogenic bladder for adults with spinal cord injuries. … resident) · After having contact with body fluids or excretions, mucous membranes, nonintact skin and wound … Examples when a suprapubic catheter is used include— · Urethral injuries or trauma · Urethral obstruction

147. Appendix F. CAUTI Prevention in Long-Term Care: Frequently Asked Questions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.html
     March 01, 2017 - Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral wounds … After having contact with body fluids or excretions, mucous membranes, nonintact skin and wound dressings … or trauma. … Bowel perforation and intra-abdominal injuries are possible during the insertion. … Management of the neurogenic bladder for adults with spinal cord injuries.

148. Table 14B: Outcome Indicators by State Supply of Health Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14b.html
     February 01, 2023 - 8,183 6,565 8,085 6,602 Composite: ACSC Overall 21,956 16,765 21,455 17,068 Pressure … 9,399 7,435 9,300 7,477 Composite: ACSC Overall 24,337 18,495 23,801 18,856 Pressure … 4,604 4,083 4,637 4,018 Composite: ACSC Overall 14,949 11,832 14,796 11,790 Pressure … 3,512 3,245 3,653 3,037 Composite: ACSC Overall 5,797 5,112 5,808 5,048 Pressure … 7,096 6,863 7,055 6,912 Composite: ACSC Overall 19,429 17,580 19,054 18,048 Pressure

149. Table 16B: Outcome Indicators by State Socioeconomic Status | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16b.html
     February 01, 2023 - 6,179 9,131 7,304 7,421 Composite: ACSC Overall 16,590 23,347 19,328 18,994 Pressure … 6,990 10,438 8,363 8,406 Composite: ACSC Overall 18,160 25,955 21,393 21,016 Pressure … 3,968 4,959 4,286 4,448 Composite: ACSC Overall 12,312 15,022 13,443 12,894 Pressure … 3,146 3,780 3,577 3,068 Composite: ACSC Overall 5,039 6,194 5,874 4,811 Pressure … 13,732 10,164 12,022 Composite: ACSC Overall 22,116 33,392 25,404 30,079 Pressure

150. Table 15B: Outcome Indicators by State Demographics | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15b.html
     February 01, 2023 - 8,040 6,786 7,702 6,976 Composite: ACSC Overall 21,669 17,341 20,812 17,696 Pressure … 9,170 7,724 8,821 7,929 Composite: ACSC Overall 23,918 19,140 23,031 19,550 Pressure … 4,402 4,279 4,338 4,320 Composite: ACSC Overall 14,429 12,531 14,135 12,525 Pressure … 3,398 3,382 3,385 3,397 Composite: ACSC Overall 5,517 5,450 5,449 5,532 Pressure … 7,202 6,782 7,004 6,990 Composite: ACSC Overall 19,879 17,354 19,092 18,022 Pressure

151. Puh-Electronic-Reports (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-electronic-reports.pdf
     February 10, 2014 - 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 … For example, the Pressure Ulcers At Risk for Delayed Healing Report; Weekly Wound Rounds Report; … DON or ADON, Nurse Manager, Wound Nurse, QI Director Root Cause Analysis for New Pressure Ulcers … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance

152. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - event type; and, detailed information about specific event types, such as the distribution of various injuries … pertaining to nine patient safety event types that represent the majority of reported preventable injuries … Event-Specific Formats pertain to nine patient safety events that represent the great majority of preventable injuries … that they represent minor injuries such as soreness, bumps, and minor abrasions. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

153. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
     October 27, 2014 - MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse Events PSI (2012) OB Trauma … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. … Eliminating birth trauma at Ascencion Health.

154. Appendix C. Case Study and Program Examples | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapc.html
     December 01, 2017 - She was assessed to have no injuries resulting from the fall. … Physical restraint—increases risk of serious injury. … Full side rails—increase risk of serious injury. … . ___ provide frequent reminders about call bell. ___ conduct trial use of a change in position/pressure … Use of pressure, position alarm. Use of hip protectors. No physical restraint use.

155. Labor and Delivery Unit Safety: Shoulder Dystocia | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-shoulder-dystocia.html
     July 01, 2023 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management. … McRoberts maneuver used concurrently with suprapubic pressure [Call time] hh:mm:ss)  ___ : ___ : __ … Suprapubic pressure: Using a closed fist over pubic bone, push in an inward and downward motion. … This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated

156. Declines in Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
     June 02, 2025 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse Events Pressure

157. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
     January 01, 2010 - Smith (2) Because of his immobility, he develops a pressure ulcer on his sacrum. … Few days later, he develops fever and his blood pressure drops. … Incontinent with open sacral/perineal wounds Consult with wound care End of life/hospice Be sure it … Trauma) Admitting service (e.g. … Protocolized care for trauma Incontinence without open sacral or perineal wounds Pre-operative

158. On-Time Preventable Hospital and ED Visits Functional Specs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
     August 01, 2017 - Ulcer Vendor determined or Wound Assessment Pressure ulcer Stage II, III, IV, or unstageable. … IF wound assessment date ≤7 days of report date AND at least one pressure ulcer with ulcer stage = … then display X in Wound • Infected wound or decubitus ulcer • Jaundice • Rash 10 Injury: Fall … X in Injury: 11 Injury: Non- Fall Related Transfer Note • • Major injury Minor injury IF …  Chest pain/angina  Dizzy/lightheaded Non-Fall-Related Injury  Major injury  Minor injury

159. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … captures the specific type of physical injury sustained in the fall as TYPE OF INJURY AS RESULT OF … that they represent minor injuries such as soreness, bumps, and minor abrasions. … and the type of the injury. … unstageable A lesion that, on admission, was a suspected Deep Tissue Injury A pressure ulcer at stage

160. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety Shoulder Dystocia (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_shoulder-dystocia.docx
     May 01, 2017 - Effects of shoulder dystocia training on the incidence of brachial plexus injury. … Shoulder dystocia and injuries: prevention and management. … McRoberts maneuver used concurrently with suprapubic pressure [Call time] (hh:mm:ss) ____:____:____ … The ideal approach is for the clinician to put pressure in the antecubital fossa of the posterior arm … This procedure is considered a heroic measure due to the significant risk of brachial plexus injury associated