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41. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4b_pdi02-pressureulcer-bestpractices.pdf
    January 01, 2012 - hospital mattress.7,8-11 o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in- terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in hospitalised patients. Int Wound J 2010;7:358-65. 7.

42. Pressure Ulcer Prevention Toolkit (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
    April 02, 2025 - Pressure Ulcer Prevention Toolkit Pressure Ulcer Prevention Toolkit Module 5 Tools Action Plan Tool … to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices Tool 5C: Assessing Comprehensive … Assessment Tool 5D: Assessing Standardized Risk Assessment Tool 5E: Assessing Care Planning AHRQ Pressure … stakeholders and staff Root cause analysis is conducted for each fall with at least moderate level of injury … admission nursing assessment, subsequent nursing progress notes, or any notes specifically documenting pressure

43. 051-Top-10-Successful-Decolonization (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/051-top-10-successful-decolonization.docx
    October 01, 2024 - areas, including: · Neck and shoulders · Between skin folds · Back of knees · Between fingers Clean wounds … , pressure injuries, and rashes.3,4 CHG is safe to use on friable skin, abrasions, superficial burns, … superficial pressure injuries, and wounds that are not packed or deep. … Wound care nurses who are comfortable with the use of CHG on wounds can provide support to other staff … FAQ: Wound Care. https://www.ucihealth.org/-/media/files/pdf/shield/hospital/hospital-step-4-faq-wound-care-doc.docx

44. Impact of AHRQ’s Patient Safety Tools: Challenge Competition | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/about/challenge-competition.html
    February 01, 2024 - Toolkit for Improving Quality of Care to decrease Patient Safety Indicator 03 (PSI-03) (reportable pressure … injuries) by 92% and save an estimated $350,000 in avoidable costs. … Implementation focused on MU Health Care’s 390-bed University Hospital, the only level I trauma center … injury rates and PSI-03 among Vizient peers to the top decile over the course of 2 years. … Injuries by 92%."

45. On-Time Pressure Ulcer Healing: Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/intro.html
    December 01, 2017 - , and other clinical details known to affect wound healing, such as nutrition, temperature, and ulcer … For example, during wound rounds, the wound nurse may prefer having treatment details for each ulcer … Healing Report ), and the entire team may attend wound rounds with a copy of the Weekly Wound Rounds … Pressure Ulcers At Risk for Delayed Healing Weekly Wound Rounds Report Weekly Pressure … Advisory Panel and Pan Pacific Pressure Injury Alliance.

46. Describe How a Plan or Provider Can Influence a Quality Measure | Agency for Healthcare Research and Quality
    www.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.

47. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - • Patient safety concerns such as falls, pressure injuries, and adverse medication events were reported … Pressure Injury Among the pressure injury events (n = 10; 3.3%), several records identified the development … of pressure injuries due to the interaction between patient pronation and poor patient mobility. … Four records identified the development of multiple pressure injuries to the lips, tongue, ears, and … The remaining pressure injuries were identified across multiple other contact points such as the coccyx

48. Self-Assessment Worksheet for Pressure Ulcer Healing | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/saworksheet.html
    December 01, 2017 - the On-Time electronic reports into current workflow to help inform pressure ulcer wound interventions … , and Pan Pacific Pressure Injury Alliance’s Prevention and Treatment of Pressure Ulcers Guidelines … ___ Wound, Ostomy, and Continence Nurses Society (WOCN) Pressure Ulcer Guidelines ___ Other (specify … ___ ___   Selection of dressings based on wound characteristics? … ___ ___   Appropriate use of topical wound agents?

49. Data Submission Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2024.xlsx
    January 01, 2024 - Documented within 24 hours of admission 0.9% 35 Stage/Category IV Unknown * * Suspected Deep Tissue Injury … Documented within 24 hours of admission 71.0% 2,897 Suspected Deep Tissue Injury No risk assessment … documented * * Suspected Deep Tissue Injury Not on admission, but documented after discovery or advancement … of pressure ulcer 78.6% 11 Suspected Deep Tissue Injury Not on admission, but documented before discovery … or advancement of pressure ulcer * * Suspected Deep Tissue Injury Unknown 69.4% 1,111 Unstageable

50. Appendix B. Prioritize Opportunities for Improvement | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apb.html
    October 01, 2017 - Pressure Injury Prevention Program Implementation Guide Appendix B. … Injury Prevention Program Implementation Guide Overview Get Ready Pressure Injury Prevention Program … Firm up your Implementation Team Leader, Core Team, Pressure Injury Team, and pressure injury champions … They might include ideas such as universal pressure injury precautions, pressure injury risk screening … Alternatively, you might decide to group ideas under the major categories in the pressure injury clinical

51. Hospital Resources | Agency for Healthcare Research and Quality
    www.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.

52. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
    January 01, 2021 - pertaining to nine patient safety event types that represent the majority of reported preventable injuries … Injuries were divided into three groups: No Injury where the incident did not result in harm, Injury … that they represent minor injuries such as soreness, bumps, and minor abrasions. … Injuries were divided into two groups: Fall considered unassisted and Fall known to be assisted. … the most advanced stage of the pressure ulcer or suspected Deep Tissue Injury being reported?”

53. 065-Dec-Staff-Faqs-Decolonization (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/065-dec-staff-faqs-decolonization.docx
    October 01, 2024 - Be especially thorough if there are any nearby wounds, pressure injuries, or breaks in the skin. … Use the CHG on superficial wounds and stage 1 and 2 pressure injuries. … Wound Cleaning For what types of wounds is CHG safe? … CHG can be applied to any superficial wounds, including stage 1 and 2 pressure injuries, friable skin … and stage 1 and 2 pressure injuries.

54. Appendix A. RACI Chart | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apa.html
    October 01, 2017 - Pressure Injury Prevention Program Implementation Guide Appendix A. … RACI Chart Previous Page Next Page Table of Contents Pressure Injury Prevention Program … Implementation Guide Overview Get Ready Pressure Injury Prevention Program Phases Appendix A

55. 3. What are the best practices in pressure ulcer prevention that we want to use? | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3.html
    October 01, 2014 - Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and … Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients … 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.

56. On-Time Pressure Ulcer Assessment | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/assessment.html
    December 01, 2017 - On-Time Pressure Ulcer Assessment AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer … Healing The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound … 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 4             Unstageable             Suspected Deep Tissue Injury

57. Functional Specifications for Pressure Ulcer Healing | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/functional-specs.html
    December 01, 2017 - 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 … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI) Ulcer Origin … : Stage 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI) Ulcer Origin … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI).

58. Saworksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/saworksheet.pdf
    April 02, 2025 - the On-Time electronic reports into current workflow to help inform pressure ulcer wound interventions … Ulcer Healing Tool BWAT – Bates-Jenson Wound Assessment Tool None of the above Other … Injury Alliance’s Prevention and Treatment of Pressure Ulcers Guidelines  Wound, Ostomy, and Continence … Pressure ulcer debridement? Selection of dressings based on wound characteristics? … Wound cleansing? Assessing the resident for pain?

59. Section 7. Tools and Resources (continued) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
    October 01, 2014 - If a skin disruption is found, the type of skin injury will need to be identified. … Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury?   … Wound care team * Wound Care Physician Directs patient care, orders tests and treatments, … medical staff, wound team, and unit staff for pressure ulcer practice Certified Wound Care

60. Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
    April 01, 2021 - Identify areas of skin at risk for developing pressure ulcers (recently renamed by expert organizations … as pressure injury) from exposure to intense or prolonged pressure, moisture, friction, and shear and … The M-Safety Lab created a patient safety display—a digital bedside display of catheter and wound information … display improved provider's awareness of indwelling urinary catheters, central venous catheters, and pressure … injuries (formerly called "pressure ulcers").