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161. 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.

162. 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.

163. 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.

164. Underreporting of quality measures and associated facility characteristics and racial disparities in US nursing home ratings. | PSNet
     psnet.ahrq.gov/issue/underreporting-quality-measures-and-associated-facility-characteristics-and-racial
     August 09, 2023 - and pressure ulcers ). … August 9, 2023 Accuracy of pressure ulcer events in US nursing home ratings. … August 24, 2022 Assessment of nursing home reporting of major injury falls for quality … September 14, 2022 Accuracy of pressure ulcer events in US nursing home ratings. … July 15, 2020 Assessment of nursing home reporting of major injury falls for quality

165. Chapter 5a. Presentation Content | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
     December 01, 2017 - Use Low Blood Pressure Precautions Slide 1. … Paralysis, tremors Loss of joint mobility, contractures Lower extremity weakness Drop in blood pressure … Physical Restraints Physical restraints increase the likelihood of serious injury resulting from … Consequences of Falls Serious injury such as hip fracture Increased risk of death associated … Use Low Blood Pressure Precautions For residents with low blood pressure: Sit on edge of bed

166. 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.

167. 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:

168. 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.

169. 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

170. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
     August 01, 2025 - ■ Improve patient outcomes (e.g., reduced pressure injuries, infection rates, falls). … , and pressure injuries compared to normal weight. … There were significant differences in NHs with high and low rates of falls, falls with injuries, pressure … Results showed there was no overall decline in pressure injury rates for treatment relative to matched … /index.html https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html

171. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2023-adverse-event-data-report.pdf
     January 01, 2023 - For all 3 years, medication events, pressure injuries/ulcers, and hospital-acquired infections (HAIs … Medication events, pressure injuries/ulcers, and hospital-acquired infections accounted for approximately … The proportion of pressure injuries/ulcers observed in 2021 (30.0%), 2022 (31.8%), and 2023 (34.2%) … were both considerably higher than the prevalence of pressure injuries observed in the OIG report, but … the OIG report only considered severe pressure injuries (Stage 3, Stage 4, and unstageable) and used

172. 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.

173. 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

174. 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.

175. 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

176. 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

177. 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

178. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
     January 01, 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.

179. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     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

180. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837898/psn-pdf
     August 24, 2022 - Preventing patient positioning injuries in the nonoperating room setting. … Preventing patient positioning injuries in the nonoperating room setting. … pressure injuries are considered a never event. … This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA … https://psnet.ahrq.gov/issue/preventing-patient-positioning-injuries-nonoperating-room-setting https: