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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. 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.

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/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/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.

68. 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

69. 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").

70. 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

71. 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).

72. 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

73. 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

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/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. 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.

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. 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

78. 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

79. C1 Prioritization Worksheet (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    June 02, 2025 - Patient Safety PSI 03 Pressure Ulcer   PSI 06 Iatrogenic Pneumothorax PSI 07 Central Venous Catheter-Related … Perioperative Pulmonary Embolism or Deep Vein Thrombosis   PSI 13 Postoperative Sepsis PSI 14 Postoperative Wound … Dehiscence PSI 15 Accidental Puncture or Laceration Obstetric PSI 17 Birth Trauma-Injury to Neonate …   PSI 18 Obstetric Trauma-Vaginal Delivery With Instrument   PSI 19 Obstetric Trauma-Vaginal Delivery … 09 Postoperative Respiratory Failure Rate PDI 10 Postoperative Sepsis Rate PDI 11 Postoperative Wound

80. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-handouts.html
    June 01, 2017 - disorders/neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound … and 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 |___| Joint pain/joint … status change |___| Mental disorder/psychosis |___| Neoplasm |___| Pneumonia |___| Pressure