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  1. www.ahrq.gov/patient-safety/reports/engage/appc.html
    March 01, 2017 - ti])) OR iatrogenesis [ti] OR iatrogenic [ti] OR ((medical [ti] OR treatment [ti] OR care [ti]) AND (injury … [ti] OR injuries [ti])) OR mishap* [ti] OR (root [ti] AND cause* [ti]) OR (failure* [ti] AND mode* [ … reducing [ab] OR reduction [ab] OR aged [mh] OR elderly OR geriatric)) OR Decubitus Ulcer [mh] OR ((pressure
  2. www.ahrq.gov/data/infographics/hac-rates_2019.html
    July 01, 2020 - Description: National efforts to reduce hospital-acquired conditions such as adverse drug events and injuriesPressure ulcers: 6% increase. Surgical site infections: 8% increase.
  3. 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
  4. www.ahrq.gov/downloads/monahrq/xls/MONAHRQ_60_Measures_List.xlsx
    March 06, 2015 - a blood transfusion and have a problem or reaction to the blood they get Yes 0349 2.0 PSI 17 Birth Trauma … - Injury to Neonate How often newborns babies have an injury or get an infection during delivery No … — 1.0 PSI 18 Obstetric Trauma Rate - Vaginal Delivery With Instrument How often women who give birth … vaginally with forceps or vacuum have a serious vaginal tear No — 1.0 PSI 19 Obstetric Trauma Rate … ) How many residents, out of 100, with a long nursing home stay, had a fall leading to a major injury
  5. 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.
  6. www.ahrq.gov/news/newsletters/e-newsletter/750.html
    February 01, 2021 - February 9, 2021 AHRQ Stats: Emergency Care of Injuries Following a Hurricane Among people who lived … direct path of a hurricane between 2005 and 2016, people age 65 years and older had the highest rate of injury-related … Source: AHRQ, Healthcare Cost and Utilization Project Statistical Brief #267: Impact of Hurricanes on Injury-Related … resource that shows recent gains in safety include declining rates of urinary tract infections and pressure … example, high-risk Black patients in long-stay nursing homes were more likely than Whites to have a pressure
  7. 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
  8. 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
  9. 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
  10. 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.
  11. 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
  12. 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
  13. www.ahrq.gov/research/findings/studies/index.html?page=99
    January 01, 2024 - Home blood pressure measurements have equal or even greater predictive value than clinic blood pressure … Association of clinical guidelines and decision support with CT use in pediatric mild traumatic brain injury … Association of clinical guidelines and decision support with CT use in pediatric mild traumatic brain injury … Clinical Decision Support (CDS), Shared Decision Making, Health Information Technology (HIT), Brain Injury … Further, their results indicated that surgeons do feel peer and social pressures related to identity
  14. www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14.html
    February 01, 2023 - 7,561 7,177 Composite: ACSC Overall 19,494 19,068 22,370 17,903 19,831 18,937 Pressure … 8,666 8,172 Composite: ACSC Overall 21,480 21,331 24,806 19,795 22,008 20,929 Pressure … 4,449 4,235 Composite: ACSC Overall 13,871 12,234 15,225 12,474 13,703 13,045 Pressure … 3,525 3,189 Composite: ACSC Overall 5,684 5,096 5,763 5,286 5,764 5,235 Pressure … 10,552 Composite: ACSC Overall 25,931 27,847 34,209 23,478 26,582 26,462 Pressure
  15. www.ahrq.gov/research/findings/studies/index.html?page=29
    January 01, 2024 - falls and pressure ulcers. … Hospital admission claims for major injury falls and pressure ulcers were linked with facility-reported … or pressure ulcer hospitalizations. … pressure ulcer hospitalizations, 67.7% were reported. … fall and pressure ulcer hospitalizations, respectively.
  16. 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
  17. www.ahrq.gov/research/findings/studies/index.html?page=195
    January 01, 2024 - There was no sex-related differences found for nadir hematocrit or rates of acute kidney injury. … Effect of sex on nadir hematocrit and rates of acute kidney injury in coronary artery bypass. … Keywords: Injuries and Wounds, Sex Factors, Kidney Disease and Health, Adverse Events, Surgery, Heart … Overall, the highest quartile of hypervigilance was associated with higher systolic blood pressure. … The largest gains were in wound closure re-gowning/re-gloving, use of clean closing instruments, and
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ostomy.pdf
    December 13, 2013 - anchoring elements to bond the epidermis to the underlying dermis, so skin is more susceptible to friction injury … ■ Peristomal skin must be protected from mechanical trauma due to use of aggressive adhesives, improper … ■ Vent frequently to prevent gas pressure from compromising the seal.
  19. www.ahrq.gov/research/findings/studies/index.html?page=425
    January 01, 2024 - RA Redefining overuse to include costs: a decision analysis for computed tomography in minor head injury … was conducted to (1) determine the testing threshold for head computed tomography (CT) in minor head injury … Redefining overuse to include costs: a decision analysis for computed tomography in minor head injury … Most payment decreases occurred by removal of comorbidity payments for present-on-admission pressure … of pressure ulcer development and payment.
  20. 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

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