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61. 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?”

62. Low Tidal Volume (Lung Protective) Ventilation Literature Review | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-lit-review.html
    January 01, 2017 - trial with 20 patients without lung disease, requiring mechanical ventilation admitted to either a trauma … regression analysis adjusted for baseline characteristics and underlying ARDS risk factors (sepsis, trauma … concentrations of TNF-alpha and of slCAM-1; Reductions of V t , with subsequently decreased peak airway pressures … The plateau airway pressures of group PV were lower than those groups of CV+PEEP (p=0.02) and CV+ZEEP … , such as multiple transfusions, trauma, sepsis, or high-risk surgery.

63. 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.

64. Saworksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/saworksheet.pdf
    June 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?

65. 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

66. 3. What are the best practices in pressure ulcer prevention that we want to use? | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/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.

67. 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.

68. References (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-litreview.docx
    January 01, 2017 - trial with 20 patients without lung disease, requiring mechanical ventilation admitted to either a trauma … regression analysis adjusted for baseline characteristics and underlying ARDS risk factors (sepsis, trauma … concentrations of TNF-alpha and of slCAM-1; Reductions of Vt, with subsequently decreased peak airway pressures … The plateau airway pressures of group PV were lower than those groups of CV+PEEP (p=0.02) and CV+ZEEP … , such as multiple transfusions, trauma, sepsis, or high-risk surgery.

69. 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).

70. 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

71. Section 7. Tools and Resources (continued) | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/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

72. 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").

73. 3. What Are the Best Practices in Pressure Ulcer Prevention that We Want to Use? (continued) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.html
    October 01, 2014 - Preventing Pressure Ulcers in Hospitals 3. … After surgery or injury, the favorite may not be possible. … Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for … National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP). … Wound, Ostomy and Continence Nurses Society.

74. 3. What Are the Best Practices in Pressure Ulcer Prevention that We Want to Use? (continued) | Agency for Healthcare Research and Quality
    www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.html
    October 01, 2014 - Preventing Pressure Ulcers in Hospitals 3. … After surgery or injury, the favorite may not be possible. … Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for … National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP). … Wound, Ostomy and Continence Nurses Society.

75. Chapter 5a. Presentation Content | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
    December 01, 2017 - Use Low Blood Pressure Precautions Slide 1. … Paralysis, tremors Loss of joint mobility, contractures Lower extremity weakness Drop in blood pressure … Physical Restraints Physical restraints increase the likelihood of serious injury resulting from … Consequences of Falls Serious injury such as hip fracture Increased risk of death associated … Use Low Blood Pressure Precautions For residents with low blood pressure: Sit on edge of bed

76. Using Pressure Ulcer Risk Assessment Tools in Care Planning (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar5_pu_riskassesst-tools.pdf
    January 01, 2012 - Adv Skin Wound Care 2001;14(3):133-7. 38 Resources • John A. … Injury Alliance. … Adv Skin Wound Care 2012; 25(4):167-88. • Rapp MP, Bergstrom N, Padhye NC. … Adv Skin Wound Care 2009;22(11):506-13. • Shanks HT, Kleinhelter P, Baker J. … Adv Skin Wound Care 2011;24(12):562-70. 39 http://www.hartfordign.org/practice/try_this/ Using Pressure

77. AHRQ-Funded Patient Safety Project Highlights (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
    August 01, 2025 - ■ Improve patient outcomes (e.g., reduced pressure injuries, infection rates, falls). … , and pressure injuries compared to normal weight. … There were significant differences in NHs with high and low rates of falls, falls with injuries, pressure … Results showed there was no overall decline in pressure injury rates for treatment relative to matched … /index.html https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html

78. 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-2021-2023-adverse-event-data-report.pdf
    January 01, 2023 - For all 3 years, medication events, pressure injuries/ulcers, and hospital-acquired infections (HAIs … Medication events, pressure injuries/ulcers, and hospital-acquired infections accounted for approximately … The proportion of pressure injuries/ulcers observed in 2021 (30.0%), 2022 (31.8%), and 2023 (34.2%) … were both considerably higher than the prevalence of pressure injuries observed in the OIG report, but … the OIG report only considered severe pressure injuries (Stage 3, Stage 4, and unstageable) and used

79. Sampleransferandintakenotes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
    June 02, 2025 - disorders/neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound … infection Endocrine/Nutritional/Metabolic  Dehydration  Malnutrition  Uncontrolled diabetes Wound … & Skin  Cellulitis  Edema  Infected wound or decubitus  Jaundice  Rash Fall-Related Injury …  Major injury  Minor injury Non-Fall-Related Injury  Major injury  Minor injury Musculoskeletal … Medication reaction  Mental status change  Mental disorder/psychosis  Neoplasm  Pneumonia  Pressure

80. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits - Transfer Note and Intake Note (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.pdf
    June 02, 2025 - disorders/neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound … infection Endocrine/Nutritional/Metabolic  Dehydration  Malnutrition  Uncontrolled diabetes Wound … & Skin  Cellulitis  Edema  Infected wound or decubitus  Jaundice  Rash Fall-Related Injury …  Major injury  Minor injury Non-Fall-Related Injury  Major injury  Minor injury Musculoskeletal … Medication reaction  Mental status change  Mental disorder/psychosis  Neoplasm  Pneumonia  Pressure