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121. Puh-Assessment (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
     April 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing On-Time Pressure Ulcer Assessment … The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool … 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 3 Stage 4 Unstageable Suspected Deep Tissue Injury

122. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
     psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
     September 27, 2023 - causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … manage potential foreign bodies, clinicians should have a low threshold for involving an experienced trauma … Consulting Editor, AHRQ’s Patient Safety Network (PSNet) Professor Department of Surgery, Division of Trauma … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.

123. Weight Summary (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
     February 10, 2014 - 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 Assess Ulcer Stage … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI) Ulcer Origin Wound Assessment … : Stage 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI) Ulcer Origin Wound Assessment … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI).

124. In Conversation with David W. Bates about Are We Safer Today? | PSNet
     psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
     February 26, 2025 - Other important factors are nursing-sensitive events, which include things like pressure injuries and … For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … will develop a dangerous pressure injury. … Some of these sensors are expensive, but pressure injuries are extremely expensive. … will take a look at your pressure injuries practices and take steps to improve those.

125. Are We Safer Today? | PSNet
     psnet.ahrq.gov/perspective/are-we-safer-today
     February 26, 2025 - Other important factors are nursing-sensitive events, which include things like pressure injuries and … For example, with pressure injuries, wetness in the bed dramatically increases the risk that somebody … will develop a dangerous pressure injury. … Some of these sensors are expensive, but pressure injuries are extremely expensive. … will take a look at your pressure injuries practices and take steps to improve those.

126. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
     December 01, 2017 - measures that include falls, residents who fall, residents with two or more falls and fall related serious injuries … Changes in staff organization Reduction of survey tags and lawsuits related to falls and injuries … 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. … across from the injury site and specify the type of injury.

127. Puh-Assessment (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
     April 02, 2025 - The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment … 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. … to <50% wound covered 5= <25% wound covered Pain Pressure Ulcer Site Pain Select … Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Suspected Deep Tissue Injury

128. PowerPoint Presentation
     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

129. Patient Safety and Adverse Events, 2011 and 2014 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb237-Patient-Safety-Adverse-Events-2011-2014.pdf
     January 01, 2014 - The PSIs focus on adverse events during the hospital stay (such as pressure ulcers), complications associated … Ulcer Rate Wounds caused by unrelieved pressure on the skin usually around bony prominences PSI … to the body’s tissues and organs following an elective surgery PSI 14 Postoperative Wound Dehiscence … requiring dialysis (70.8 percent), postoperative wound dehiscence (70.3 percent), pressure ulcers … The 10 risk-adjusted rates contributing to PSI 90 are as follows:  Pressure Ulcer Rate (PSI 03) 

130. A Tale of Two Falls | PSNet
     psnet.ahrq.gov/web-mm/tale-two-falls
     March 27, 2024 - treated with albuterol without improvement, which prompted the initiation of bilevel positive airway pressure … She sustained head trauma, blunt trauma of the cervical spine, right rib fractures, and a right femur … initial ED presentation, she was alert and oriented, and her vital signs were stable, with a blood pressure … We do not know if the patient’s fall at home resulted in head trauma, which may have predisposed her … second case or contributed to a worse injury.

131. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
     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.

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33561/psn-pdf
     September 15, 2024 - , while being cared for in a healthcare setting Care management events Patient death or serious injury … associated with unsafe administration of blood products Maternal death or serious injury associated … of a neonate associated with labor or delivery in a low-risk pregnancy Patient death or serious injury … associated with a fall while being cared for in a healthcare setting Any stage 3, stage 4, and unstageable pressure … Because Never Events are devastating and preventable, health care organizations are under increasing pressure

133. 4 Tk2 T1-Medical Care Referral Form Word Doc For Html Only (doc file)
     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 ?

134. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality
     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

135. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
     psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
     March 09, 2022 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic pressures, 52–54 some … Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model. … Quantification of leakage pressures after durotomy repairs in the canine. … January 23, 2019 Classifying errors in preventable and potentially preventable trauma

136. ROI for a fall prevention intervention: invest a little, save a lot. | PSNet
     psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save-lot
     September 13, 2017 - Falls and falls with injury are significant sources of morbidity and mortality and can have substantial … This study showed  that after implementing the Fall TIPS program, falls and falls with injury decreased … November 3, 2021 Trauma resuscitation errors and computer-assisted decision support. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

137. Documentation and Coding for Patient Safety Indicators (pdf file)
     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

138. Statistical Brief #64: Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf
     December 01, 2008 - In contrast, 56.5 percent of adult patients with a principal diagnosis of pressures ulcers were 65 … Paralysis and spinal cord injury were common co- existing conditions among younger adults hospitalized … In-hospital death occurred in 11.6 percent of stays with pressures ulcers noted as a secondary diagnosis … Patients 65 and older accounted for 56.5 percent of adult patients with a principal diagnosis of pressures … Paralysis and spinal cord injury were prominent among younger patients, while fluid and electrolyte

139. 4 Tk2 T1-Medical Care Referral Form (pdf file)
     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 ?

140. Statistical Brief #3
     hcup-us.ahrq.gov/reports/statbriefs/sb3.jsp
     April 01, 2006 - burden of hospitalizations related to pressure sores (figure 1). … The mean charge for hospital stays principally for pressures sores was $37,800, but charges varied by … paralysis, spinal cord injury, substance abuse, malnutrition, multiple sclerosis, stroke, and senility … 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