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21. Table 15A: Outcome Indicators by County Demographics | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15.html
    February 01, 2023 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Conditions 8,997 6,894 8,597 6,888 Composite: ACSC Overall 22,706 18,412 21,951 18,376 Pressure … Conditions 4,856 4,215 4,625 4,246 Composite: ACSC Overall 14,792 13,022 14,282 13,066 Pressure … Conditions 3,483 3,293 3,410 3,308 Composite: ACSC Overall 5,671 5,408 5,482 5,469 Pressure … Conditions 3,483 3,293 3,410 3,308 Composite: ACSC Overall 5,671 5,408 5,482 5,469 Pressure

22. C1 Prioritization Worksheet (xls file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    July 01, 2016 - 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

23. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
    July 01, 2020 - due to procedures, as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/Pressure Injuries Obstetric Adverse Events Falls Clostridioides difficile Infections Central … Ulcers/ Pressure Injuries 21.7 23.5 22.7 23.0 6% Surgical Site Infections 2.5 2.5 2.5 2.7 8% … Pressure Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs for 17 procedures w/CDC SCIP

24. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/index.html
    March 01, 2024 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … 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.

25. 4 Tk2 T1-Medical Care Referral Form (pdf file)
    www.qualitymeasures.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 ?

26. 5. How do you measure fall rates and fall prevention practices? | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
    January 01, 2013 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Also, staff may feel pressure to underreport borderline cases because of concern that their unit will … The NDNQI definitions for injury follow: None—patient had no injuries (no signs or symptoms) resulting … " Minor—resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication … The actual rates of falls with trauma occurring within the hospital may be found on the Medicare data

27. Measuring Fall and Fall-Related Injury Rates and Prevention Practices (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/webinars/webinar5_falls_measuringratespractices.pdf
    January 01, 2013 - • Level of injury for each fall. … rates such as— – Falls related to toileting needs – Falls related to risk factors (medicines, blood pressure … — • Collects data after a patient falls • Seeks to find out if the patient has immediate risk of injuries … Injury Rates Data Needed for Fall and Fall-Related Injury Rates How Often To Calculate Fall and Fall-Related … Injury Rates How To Calculate Fall and Fall-Related Injury Rates Improving Data for Fall and Fall-Related

28. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
    January 01, 2019 - due to procedures, as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/ Pressure Injuries 21.7 23.5 22.7 23.0 6% 17.4 Surgical Site Infections 2.5 2.5 2.5 … Pressure Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs for 17 procedures w/CDC SCIP … Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs for 17 procedures w/CDC SCIP+5

29. Initial Risk Assessment for Immobility-Related Pressuer Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-203-fullreport.pdf
    April 10, 2017 - Ulcer Advisory Panel (EPUAP) — “A pressure ulcer is localized injury to the skin and/or underlying … ulcers are a serious iatrogenic injury. … They may have preexisting wounds or altered skin integrity due to a variety of factors related to their … Are pressure ulcers preventable? A survey of experts. Adv Skin Wound Care 2001; 14(5):244-8. … Unavoidable Pressure Injury. J Wound Ostomy Continence Nurs 2014; 41(4): 313-34.

30. Introduction to the Quality Indicators Best Practices Tool (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
    June 05, 2016 - Best practices forms exist for the following 14 PSIs: • PSI 03 Pressure Ulcer Rate • PSI 05 Retained … Pulmonary Embolism or Deep Vein Thrombosis Rate • PSI 13 Postoperative Sepsis Rate • PSI 14 Postoperative Wound … 03 Neonatal Blood Stream Infection Rate • PDI 01 Accidental Puncture or Laceration Rate • PDI 02 Pressure … Postoperative Respiratory Failure Rate • PDI 10 Postoperative Sepsis Rate • PDI 11 Postoperative Wound … • PSI 17 Birth Trauma Rate―Injury to Neonate: The existing literature on birth trauma and injury

31. Indwelling Urinary Catheter Indications Facilitator Notes (doc file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
    April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention due to a spinal cord injury … the last row on this table), urology consultation should be considered for prostatitis and urethral trauma … Of note, catheters are appropriate in the case of urinary incontinence with open wounds if the urine … cannot be kept from contaminating the wounds using other strategies. … . · Not all open sacral/hip wounds require an indwelling catheter if the wound can be kept clean by other

32. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
    December 01, 2017 - Include alarms attached to a wheelchair and consider all types of pressure or position change alarms … Item 14 asks if the resident's blood pressure was taken after the fall. … If so, the nurse should check the injury site and which side of the resident's body sustained the injury … across from the injury site and specify the type of injury. … https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html

33. Tool 3F: Orthostatic Vital Sign Measurement | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html
    January 01, 2013 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Have possible spinal injuries. Have lower extremity or pelvic fractures. … Blood pressure cuff of correct size for the patient. … Check sitting blood pressure and pulse. … Support the forearm at heart level when taking the blood pressures to prevent inaccurate measurement.

34. Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/research/findings/studies/index.html?page=1
    January 01, 2024 - and Wounds (207) Inpatient Care (220) Intensive Care Unit (ICU) (264) Kidney Disease and … Outcome measures included hypertension, systolic blood pressure >130 mmHG, and hyperglycemia. … center (NTC) and were diagnosed with a traumatic injury with an injury severity score of greater than … , major chest injury, and presentation at a teaching hospital. … , Injuries and Wounds Cron DC , Braun HJ , Ascher NL Sex-based disparities in access to

35. PMCoE PICU Expert Work Group and Leadership Team Roster (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-6-b-workgroup.pdf
    September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to

36. Section 6-B, PMCoE PICU Expert Workgroup and Leadership Team Roster (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-6-b-pmcoe-picu-expert-workgroup.pdf
    September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to

37. Section 6-B, Expert Workgroup Roster and Materials (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
    September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to

38. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
    December 01, 2012 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … 7,115 9,257 6,892 Composite: ACSC Overall 17,570 24,934 20,620 17,662 23,518 18,337 Pressure … 10,435 7,884 Composite: ACSC Overall 19,406 27,524 22,656 19,821 25,958 20,278 Pressure … 3,002 3,777 3,248 Composite: ACSC Overall 5,094 6,963 6,484 4,695 6,310 5,297 Pressure … 13,343 9,904 Composite: ACSC Overall 24,097 33,576 25,800 27,762 32,363 25,065 Pressure

39. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
    November 01, 2017 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .

40. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Slide Presentation | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
    September 01, 2017 - Resources CANDOR Family-Centered Rounds Toolkit MATCH Toolkit NICU Toolkit Pressure … Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … None or no injury: The patient is free of injuries (no signs or symptoms) resulting from a fall … Death: The patient died as a result of injuries sustained from the fall (not from physiologic events … Slide 13: NDNQI Definitions of Fall Injury None: No injury Minor: Resulted in bruise, abrasion