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161. 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

162. 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

163. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet
     psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
     September 01, 2012 - Left ventricular pressures can be measured with a catheter advanced across the aortic valve. … instance, the operator was falsely reassured by the presence of a normal pressure reading, suggesting … that the tip of the catheter was not against the wall, when in fact, the pressure sensor was likely … Radiology technologists and nurses, who should be reviewing images and pressures during the case, can … Immediate recognition of iatrogenic injuries during cardiac catheterization enables more timely and effective

164. 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.

165. 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.

166. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. | PSNet
     psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
     November 25, 2020 - His left calf was noted to be very tense; the surgeon confirmed elevated compartment pressures and performed … Pain out of proportion to injury severity is a hallmark sign of CS and should have been investigated … from fractures or crush injuries. … Unless there is an associated arterial injury, compartment pressure is rarely elevated sufficiently to … Interobserver variability in the measurement of lower leg compartment pressures.

167. The effect of bedrails on falls and injury: a systematic review of clinical studies. | PSNet
     psnet.ahrq.gov/issue/effect-bedrails-falls-and-injury-systematic-review-clinical-studies
     March 15, 2016 - The effect of bedrails on falls and injury: a systematic review of clinical studies. … that outdated design and incorrect assembly, rather than bedrails themselves, contributed to such injuries … The effect of bedrails on falls and injury: a systematic review of clinical studies. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

168. Spotlight (pdf file)
     psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
     January 01, 2024 - – In a study of 165 patients undergoing wound exploration after hand laceration, 32% of tendon injuries … with the hand in the same position as it was during the injury. – Wounds should be evaluated for active … • A blood pressure cuff applied proximal to the wound is another option. 19 Hand Examination (5 … ● If a tendon injury cannot be ruled out after wound exploration and functional testing, assume an … Medico-legal risks associated to hand and wrist trauma. World J Crit Care Med. 2022;11(1):40- 47.

169. HCUP Statistical Brief #3: Hospitalizations Related to Pressure Sores, 2003 (pdf file)
     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

170. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865655/psn-pdf
     April 24, 2024 - His left calf was noted to be very tense; the surgeon confirmed elevated compartment pressures and performed … from fractures or crush injuries. … Unless there is an associated arterial injury, compartment pressure is rarely elevated sufficiently … Interobserver variability in the measurement of lower leg compartment pressures. … J Trauma. 2006;60(5):1037-1040. [ Available at] 14.

171. Preventing pressure ulcers: the goal is zero. | PSNet
     psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero
     September 30, 2010 - Commentary Preventing pressure ulcers: the goal is zero. … Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007;33(10):605-10. … Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007;33(10):605-10. … October 2, 2024 A randomized trial of a multifactorial strategy to prevent serious fall injuries … August 27, 2013 Preventing in-facility pressure ulcers as a patient safety strategy:

172. 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

173. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
     psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
     November 27, 2019 - The Case A 65-year-old man presented to a Level III trauma center with bilateral lower extremity paralysis … The patient was then transferred to a Level I trauma center that could provide a higher level of care … that results in wide fluctuation of blood pressure. … The combination of a supraphysiologic blood pressure target and the patient’s altered blood pressure … ’s spinal cord injury.

174. Disposition of Comments for Pressure Ulcer Treatment Strategies: Comparative Effectiveness (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/pressure-ulcer-treatment_disposition-comments.pdf
     May 08, 2013 - Infections in pressure ulcers as well as other acute and chronic wounds delay healing and add to the … Certain wound treatments may be easier to test in large RCTs on full thickness chronic wounds that … We agree that evidence on other types of wounds may have relevance to pressure ulcer care. … The definition of “unstageable” and suspected deep tissue injury” pressure ulcers should be included … Effectiveness of mattress overlays in reducing interface pressures during recumbency. Journ.

175. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74252/psn-pdf
     January 12, 2022 - Or they were used to a certain type of protective foam to prevent pressure injuries and now they must … With regard to pressure injuries for patients in the prone position, staff had to think about how to … We saw pressure injuries and as soon as these events occurred, we saw staff problem-solving and doing … The other thing that we saw related to pressure injuries was a type of skin lesion the National Pressure … COVID skin looks very much like deep tissue injury, or other types of pressure injury, but is actually

176. Preventing patient positioning injuries in the nonoperating room setting. | PSNet
     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.

177. 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

178. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/850159/psn-pdf
     June 07, 2023 - characteristics and reporting patterns for two measures of nursing home care quality (falls with major injury … and pressure ulcers). … does-nursing-home-compare-reflect-patient-safety-nursing-homes https://psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings

179. 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

180. 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