-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhosp-reports-slides.pptx
November 30, 2013 - Major injury
Minor injury
Non-Fall-Related Injury
Major injury
Minor injury
Musculoskeletal
Joint pain … & Skin
Cellulitis
Edema
Infected wound or decubitus
Jaundice
Rash
Treatment Unavailable at Transferring … & Skin Injury: Fall Related Injury : Non-Fall Related Musculoskeletal Abnormal Labs or Anemia Fever/ … or Skin Fall-Related Injury Non-Fall-Related Injury Abnormal Lab Results Fever /
Possible Infection … Disease Asthma Circulatory Problems Hypertension or Renal Failure Gastroenteritis Angina Pectoris Falls /Trauma
-
www.ahrq.gov/patient-safety/settings/hospital/index.html
February 01, 2025 - Preventing Pressure Ulcers in Hospitals is a toolkit that assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. … injury prevention.
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form_Word_doc_for_html_only.doc
April 02, 2025 - including recent fever pattern and change in recent/current health status:
CURRENT VITAL SIGNS
Blood pressure … Suspected minor injury
Yes No ?
Suspected serious injury
Yes No ? … New or increasing pus draining from wound
Y
N
?
New breakdown
Y
N
? … New or expanding redness around wound
Y
N
?
Pain / tenderness
Y
N
?
Warmth
Y
N
?
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - Few days later, he develops fever and his blood pressure drops. … Keeps patients from having to get up to urinate, protecting them from injury. … Trauma)
Admitting service (e.g. … Is the patient incontinent with open sacral or perineal wounds? … Protocolized care for trauma
Incontinence without open sacral or perineal wounds
Pre-operative
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
March 15, 2016 - PDI 02 Pressure Ulcer Rate (stage
III, IV, Unstageable)
Diagnosis and site of pressure ulcer must … PSI 18,
PSI 19
OB Trauma – Vaginal Delivery
With Instrument
OB Trauma – Vaginal Delivery
Without … X
PDI 11 Postoperative Wound
Dehiscence Rate
X Depth of the wound dehiscence:
external/superficial … X
PSI 14 Postoperative Wound
Dehiscence
X Depth of the wound dehiscence:
external/superficial vs … PSI 18
PSI 19
OB Trauma – Vaginal
Delivery With Instrument
OB Trauma – Vaginal
Delivery Without
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
May 01, 2014 - Positive culture
If yes, positive for:_______________________________
CURRENT VITAL SIGNS
Blood pressure … New or increasing pus draining from wound
Y N ? New breakdown
Y N ? … New or expanding redness around wound
Y N ? Pain / tenderness
Y N ? Warmth
Y N ? … Suspected minor injury Yes No ?
Suspected serious injury Yes No ?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-icu-slides.pptx
January 01, 2017 - Patients
Adverse Events4
9 patients had 14 adverse events (<1% of activities)
Falls to knees without injury … (5)
Systolic blood pressure <90 mmHg (4)
Oxygen saturation <80% (3)
Nasal feeding tube removal (1) … Systolic blood pressure >200 mmHg (1)
No extubations
No patients required added therapy or increased … sessions (i.e., 6 per 1,000 PT treatment)
80% of events were transient physiological (heart rate, blood pressure … Safety Program for Mechanically Ventilated Patients
5-Year Sustainability of Time to PT
Postacute Lung Injury
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
April 02, 2025 - purchasing
• Sentinel
event
• Publicly
reported
• Public
perception
• Marketing
• Competitive
pressure … Rate on scale of 10 (agree/high) to 0 (disagree/low)
PSI 14 Postoperative
Wound … Dehiscence
PSI 15 Accidental
Puncture or Laceration
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
-
www.ahrq.gov/hai/pfp/interimhac2013-ref.html
December 01, 2014 - Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers
Agency for Healthcare Research and Quality. … Eliminating facility-acquired pressure ulcers at Ascension Health .
-
www.ahrq.gov/hai/pfp/hacrate2013-refs.html
October 01, 2015 - Injury From Falls
Barrett JA, Bradshaw M, Hutchinson K, et al. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers
Agency for Healthcare Research and Quality.
-
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Remember, pressure ulcers are areas of soft tissue damage caused by pressure or pressure and shear. … If unsure whether it is a pressure ulcer, get help from the wound care nurse or another experienced clinician … Typically, this comprehensive evaluation is performed by an "outside" expert such as a wound nurse or … Therefore, consider performing a comprehensive skin assessment every 3 months with a wound care nurse … Pressure ulcers may take several days to develop after a severe pressure injury.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/062-protocol-training-decolonization-with-chg.pptx
October 01, 2024 - Superficial pressure injuries (stages 1 and 2)
CHG should also be applied over sutured or stapled wounds … Clean wound carefully with CHG. … Apply CHG with firm pressure, unless the wound is over a bony prominence. … Using the CHG on superficial wounds, and stage 1 and 2 pressure injuries. … Refer to the slides on Wound Care.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
April 02, 2025 - Patient Safety PSI 03 Pressure Ulcer 1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y
PSI 06 Iatrogenic … 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y
PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y
Obstetric PSI 17 Birth Trauma-Injury … to Neonate 0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y
PSI 18 Obstetric Trauma-Vaginal Delivery … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y
PDI 11 Postoperative Wound
-
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
-
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.
-
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
-
www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s)
present … , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh]
OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … Tissue Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ostomy/wound Mgmt. 2016 Nov;62(11):30.
d Weiser TG, Semel ME, Simon AE, et al. … Ostomy Wound Manage. 2016 Nov;62(11):30-8.
65 Mendizabal A, Thibault DP, Willis AW.
-
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.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/ereports.html
December 01, 2017 - 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 during … Information that displays on the Weekly Pressure Ulcer Treatment Summary Report, the Weekly Wound Rounds … Uses
DON or ADON, Nurse Manager, Wound Nurse, QI Director
Root Cause Analysis for New Pressure … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2014chartbooks/hispanichealth/2014nhqdr-hispanichealth-pt2.pdf
July 01, 2015 - - injury to newborn per 1,000 live births Better No Change
Obstetric trauma per 1,000 vaginal deliveries … Trends:
■ Birth trauma-neonatal injury rates fell from 2.6 per 1,000 live births in 2004 to 1.9 … ■ Between 2004 and 2012, birth trauma-neonatal injury rates fell for all racial/ethnic
groups. … Birth trauma—injury to neonate per 1,000 live births, by
race/ethnicity, 2004-2012
Key: API = Asian … 2011 2012
R
at
e
p
e
r
1
,0
0
0
L
iv
e
B
ir
th
s
Total White Black API Hispanic
Birth trauma—injury