-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
April 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
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www.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
-
hcup-us.ahrq.gov/reports/statbriefs/sb3.pdf
April 01, 2006 - t
hospit
treatm
were f
respon
admis
five m
condit
pneum
infecti
itis, an
Amon
princip
comm
includ
injury … ean charge for hospital
principally for pressures
was $37,800, but charges
by payer; e.g., the aver … percent), paralysis (27.4 percent), senility (22.7 percent), malnutrition (17.8 percent),
spinal cord injury … Paralysis, spinal cord injury, and
substance abuse were prominent among younger patients, while malnutrition … 21.7
36.6
47.6
10.5
74.8
13.913.2
43.1
14.1
8.76.7
0
20
40
60
80
Paralysis Spinal cord
injury
-
psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - were worse when supine, but nocturnal headaches can be the presenting sign of elevated intracranial pressure … keep patients awake at night should prompt repeat imaging given the concern for elevated intracranial pressure … which allows time for the brain to adapt to tissue displacement and modestly increased intracranial pressure … Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. … Trauma Surg Acute Care Open . 2018;3(1):e000129. [ Free full text ] Borst J, Godat LN, Berndtson AE,
-
psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
April 27, 2022 - wound. … Trauma-induced coagulopathy: what you need to know. … Vascular injury and complication in neurosurgical spine surgery. … Hetastarch during initial resuscitation from trauma. … J Trauma . 2011;70(5 Suppl):S19-S21. [ Available at ] Hahn RG.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar3_pu_staffroles.pdf
January 01, 2014 - Program.
8
Wound Care Team: Roles and Duties
• Serve as your hospital’s content experts on
pressure … ulcer
injury prevention … Nursing 2014 survey results: Wound care and
prevention. … Advances in Skin and Wound Care. 2010; 23(3):120-31.
• Levine J, et al. … Advances in Skin and Wound Care. 2007;
20(1):34-38.
37
Staff Roles and Training forYour Pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
January 01, 2022 - injuries or complications of pressure injuries present on admission (POA)
was significantly higher … injuries or complications of pressure injuries
present on admission (13.4% vs. 4.7%) and catheter-associated … When the individual AE rates were analyzed by sex, the AE rate for advancing
pressure injuries or complications … of pressure injuries POA was significantly higher for males than
females (7.2% vs. 4.9%). … Pressure Injury/Ulcer
(PI)
Advancing PI or Secondary Comorbidity in PI Present
on Admission
New
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
January 01, 2022 - injuries or complications of pressure injuries present on admission (POA)
was significantly higher … injuries or complications of pressure injuries
present on admission (13.4% vs. 4.7%) and catheter-associated … When the individual AE rates were analyzed by sex, the AE rate for advancing
pressure injuries or complications … of pressure injuries POA was significantly higher for males than
females (7.2% vs. 4.9%). … Pressure Injury/Ulcer
(PI)
Advancing PI or Secondary Comorbidity in PI Present
on Admission
New
-
hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_2_4.jsp
January 01, 2005 - 192
Umbilical cord complication
216.7
8.676
2.0
0.014890
7,100
175
193
Trauma … complications following abortion)
2.7
0.175
2.6
0.110958
12,800
831
235
Open wounds … examination/evaluation
16.7
4.161
*
*
*
*
98
Essential hypertension (high blood pressure … 246
Fever of unknown origin
86.4
4.815
3.4
0.073659
13,300
507
244
Other injuries … during pregnancy)
220.3
8.652
3.5
0.043953
12,000
324
236
Open wounds of extremities
-
psnet.ahrq.gov/issue/preventing-patient-positioning-injuries-nonoperating-room-setting
November 21, 2012 - Commentary
Preventing patient positioning injuries in the nonoperating room setting … Preventing patient positioning injuries in the nonoperating room setting. … Hospital-acquired pressure injuries are considered a never event . … This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA … Preventing patient positioning injuries in the nonoperating room setting.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
April 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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.pdf
April 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
-
www.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
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
April 02, 2025 - 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
-
qualityindicators.ahrq.gov/Downloads/Modules/V2023/AHRQ_QI_Indicators_List.pdf
October 01, 2023 - • PSI 02 - Death Rate in Low-Mortality Diagnosis Related
Groups (DRGs)
• PSI 03- Pressure … Fracture Rate
• PSI 09- Postoperative Hemorrhage or Hematoma Rate
• PSI 10- Postoperative Acute Kidney Injury … or Deep
Vein Thrombosis (PE/DVT) Rate
• PSI 13- Postoperative Sepsis Rate
• PSI 14 - Postoperative Wound … Rate - Injury to Neonate
• PSI 18 - Obstetric Trauma Rate - Vaginal Delivery with
Instrument
• PSI … 19- Obstetric Trauma Rate - Vaginal Delivery
without Instrument
• PSI 90- Patient Safety and Adverse
-
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
-
www.ahrq.gov/hai/pfp/haccost2017-appendix.html
November 01, 2017 - , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … ] OR "Decubitus Ulcer" [tiab] OR "Pressure Sore" [MeSH] OR "Pressure Sore" [tiab] OR "Suspected Deep … 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. … The cost of serious fall-related injuries at three Midwestern hospitals.
-
www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
April 01, 2025 - the population at risk numbered at least 100, the highest rates for both 2021 and 2022 were worsening pressure … injuries that were present on admission (2021: 4.9%, 2022: 6.0%), hypoglycemic events (4.7% for both … Pressure Injury. Surgery/Anesthesia. Venous Thromboembolism. Other. … determined that national efforts to reduce hospital-acquired conditions such as adverse drug events and injuries
-
psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - The anesthesiologist then noted a rapid decrease in the patient’s blood pressure and increasing tachycardia … , indicating a possible vascular injury. … Pressure was applied and vascular surgery was consulted. … of underreporting of vascular injury. … How can this type of injury be prevented?
-
psnet.ahrq.gov/continuing-education
February 26, 2025 - in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. … A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury … A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without … The commentary highlights the importance of evaluating patient risk of wound infection and poor wound … healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up