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201. A Potent Medication Administered in a Not So Viable Route | PSNet
     psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
     July 20, 2016 - Use of vasopressors to raise blood pressure and improve perfusion in fluid refractory shock is considered … standard of care ( 1 ), with vasopressors generally titrated to achieve a mean arterial pressure of … Vasopressor medications achieve their desired effects on blood pressure through powerful vasoconstriction … of 49 hours (± 22 hours).( 4 ) While 2% of patients experienced vasopressor extravasation, no tissue injuries … Management of extravasation injuries: a focused evaluation of noncytotoxic medications.

202. A comprehensive program to reduce rates of hospital-acquired pressure ulcers in a system of community hospitals. | PSNet
     psnet.ahrq.gov/issue/comprehensive-program-reduce-rates-hospital-acquired-pressure-ulcers-system-community
     May 12, 2021 - Study A comprehensive program to reduce rates of hospital-acquired pressure ulcers … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … This implementation study sought to reduce incidence of pressure ulcers in hospitalized patients using … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … injury policy.

203. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49796/psn-pdf
     June 01, 2017 - did not recover spontaneous circulation for more than 30 minutes and sustained severe anoxic brain injury … For example, the trauma surgery service did not routinely perform a clamping trial before chest tube … most common complication), recurrent pneumothorax, infection (including empyema), organ or vessel injury … Complications following thoracic trauma managed with tube thoracostomy. Injury. 2012;43:46-50. … Complications of tube thoracostomy for acute trauma. Am J Surg. 1980;140:738-741.

204. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
     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

205. Early Mobility in the Intensive Care Unit: Slide Presentation | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
     February 01, 2017 - Systolic blood pressure <90 mmHg (4). Oxygen saturation <80% (3). … Systolic blood pressure >200 mmHg (1). No extubations. … (i.e., 6 per 1,000 PT treatment): 80% of events were transient physiological (heart rate, blood pressure … Subjects: 2,176 trauma and burn ICU patients, Pre (n=1044) and post (n=1132) EM program. … Slide 23: 5-Year Sustainability of Time to PT Postacute Lung Injury Diagnosis 8 Post-QI → earlier

206. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44388/psn-pdf
     October 14, 2015 - The study looked at four nursing-sensitive adverse outcomes: pressure ulcers, falls with injuries, catheter-associated … hospitals had significantly fewer of these hospital-acquired conditions, except for patient falls with injury … medicares-policy-not-pay-treating-hospital-acquired-conditions-impact https://psnet.ahrq.gov/issue/preventing-falls-injury

207. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet
     psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
     October 31, 2023 - 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.

208. Section 6-B, Expert Workgroup Roster and Materials (pdf file)
     www.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

209. Section 6-B, PMCoE PICU Expert Workgroup and Leadership Team Roster (pdf file)
     www.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

210. PMCoE PICU Expert Work Group and Leadership Team Roster (pdf file)
     www.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

211. 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.

212. 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

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866205/psn-pdf
     July 10, 2024 - Ironically for this case, the greatest risk of bleeding from ALIF is usually from injury to a major … the wound. … Trauma-induced coagulopathy: what you need to know. J Trauma Acute Care Surg. 2024;96(2):179-185. … Vascular injury and complication in neurosurgical spine surgery. … Hetastarch during initial resuscitation from trauma. J Trauma. 2011;70(5 Suppl):S19-S21.

214. 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
     June 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 ?

215. 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.

216. Introduction to the Quality Indicators Best Practices Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
     June 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

217. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     datatools.ahrq.gov/action-alliance/wp-content/uploads/sites/8/2025/09/qsrs-2021-2023-adverse-event-data-report.pdf
     January 01, 2025 - 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

218. Challenges and potential solutions for patient safety in an infectious-agent-isolation environment: a study of 484 COVID-19-related event reports across 94 hospitals | PSNet
     psnet.ahrq.gov/issue/challenges-and-potential-solutions-patient-safety-infectious-agent-isolation-environment
     October 27, 2021 - The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related … October 13, 2018 Trauma Resuscitation Using in situ Simulation Team Training (TRUST) … July 21, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.

219. Data Submission Dashboard Data 2025 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2025.xlsx
     January 01, 2025 - 19.8% CFER-H V1.2 Other 1395521 53.4% CFER-H V1.2 Perinatal 34593 1.3% CFER-H V1.2 Pressure … Injury 125845 4.8% CFER-H V1.2 Surgery or Anesthesia 135757 5.2% CFER-H V1.2 Venous … 14.6% CFER-H V2.0 Other 611888 57.5% CFER-H V2.0 Perinatal 39507 3.7% CFER-H V2.0 Pressure … Injury 19650 1.8% CFER-H V2.0 Surgery 39571 3.7% CFER-H V2.0 Venous Thromboembolism

220. Too Hot For Comfort | PSNet
     psnet.ahrq.gov/web-mm/too-hot-comfort
     May 19, 2015 - Commonly used agents that cause severe extravasation injuries include antineoplastic, inotropic, or osmotically … Use to Promote Wound Healing In contrast, the wound healing literature generally supports the use … Treating chronic and acute wounds with warming: review of the science and practice implications. … Local heat increases blood flow and oxygen tension in wounds. Arch Surg. 1987;122:221-225. … March 5, 2025 WebM&M Cases Under Pressure: Tracheostomy