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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
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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
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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
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psnet.ahrq.gov/issue/research-practice-factors-affecting-implementation-prospective-targeted-injury-detection
August 04, 2021 - From research to practice: factors affecting implementation of prospective targeted injury-detection … From research to practice: factors affecting implementation of prospective targeted injury-detection … five hospitals faced in implementing new systems for prospective detection of adverse drug events and pressure … From research to practice: factors affecting implementation of prospective targeted injury-detection
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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
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www.ahrq.gov/topics/healthcare-costs.html
Patient Falls by 21 Percent
Chartbook on Care Affordability
Connecticut Hospital Reduces Pressure … Injuries Using AHRQ Toolkit
Estimating the Costs of Primary Care Transformation: A Practical Guide
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digital.ahrq.gov/technology/fast-healthcare-interoperability-resources-fhir
January 08, 2025 - Study protocol: Collaboration Oriented Approach to Controlling High Blood Pressure … Study protocol: Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) in adults … Project Name
Collaboration-Oriented Approach to Controlling High Blood Pressure (COACH) … clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury … clinical decision support to improve venous thromboembolism prophylaxis for patients with traumatic brain injury
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psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
April 26, 2023 - March 7, 2018
Pressure Injury Prevention in Hospitals Training Program. … October 18, 2017
Preventing Falls With Injury.
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digital.ahrq.gov/2020-year-review/research-summary/supporting-clinicians-improve-decision-making-and-patients-care-emerging-research
January 01, 2020 - patient care in hazardous decision-making environments fraught with excessive cognitive loading and time pressure … Hopkins University are investigating the use of AI to provide CDS in the detection of acute kidney injury … development and implementation of this AI-driven CDS system for detection and treatment of acute kidney injury … developed EHR-linked CDS tool, Peds & TeenBP, on screening and treatment of hypertension and high blood pressure … The research team aims to advance the standard practice of blood pressure measurement, increase hypertension
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - in one
hour (versus six hours in this case)
• Prolonged operative time is a surrogate for tissue injury … Deviation in the face of production
pressure is a recipe for disaster. … Injury. 2018;49(1):130‐134.
doi:10.1016/j.injury.2017.09.002
7. … Pressure Ulcer Prevention in the Hospital Setting Using Silicone Foam Dressings. … Injury. 2020;S0020-1383(20)30424-1.
doi:10.1016/j.injury.2020.05.017
10.
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hcup-us.ahrq.gov/reports/statbriefs/sb267-Hurricanes-Injuries-ED-Visits-2005-2016.pdf
January 01, 2016 - , excluding those with
skull fracture; internal injury of chest, abdomen, and pelvis; open wound of … ; burns; injury to nerves and spinal cord;
certain traumatic complications and unspecified injuries; … unspecified; effects of
heat and light; hypothermia; other effects of reduced temperature; effects of air
pressure … and water pressure; asphyxiation; effects of other deprivation; adult
and child abuse, neglect and … initial encounters, subsequent encounters, and sequela
T79 series • Certain early complications of trauma
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications.pptx
April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention, due to spinal injury. … when no or little urine is seen in bladder
Consider urology consultation for prostatitis and urethral trauma … Closed pressure ulcers: stage I, deep tissue injury No No, unless has chronic ISC needs Yes, if the patient … require an indwelling urinary catheter if the wound can be kept clean by other methods
Use alternatives … J Wound Ostomy Continence Nurs. 2020;47(6):601-18. PMID: 33201147.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-factsheet.docx
January 01, 2017 - Emerging evidence links protective tidal ventilation to decreased incidence of acute lung injury (ALI … Use at least 5 cm H2O positive end expiratory pressure (PEEP).
Why wait? … not yet have ARDS and particularly those with risk factors to prevent progressive development of lung injury … Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation … What tidal volumes should be used in patients without acute lung injury?
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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
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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)
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - hypervolemia, leading to mismanagement of her hypertensive emergency, irreversible progression of cardiac injury … to the ED.1
12
12
Background (4)
The presence of pulmonary edema with hypoxemia and acute kidney injury … with an especially elevated diastolic pressure. … nitroglycerin (given that nitroprusside is relatively contraindicated in the setting of acute kidney injury … treating hypertensive emergencies, choosing appropriate antihypertensives for patients with end-organ injury
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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.
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psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - wound care and intravenous antibiotics. … Despite animal studies suggesting sealant alone can withstand high hydrostatic pressures,52–54 some remain … Suture Choice in Lumbar Dural Closure Contributes to Variation in Leak Pressures: Experimental Model. … Quantification of leakage pressures after durotomy repairs in the canine. … Occult spinal pseudomeningocele following a trivial injury successfully treated with a lumboperitoneal
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psnet.ahrq.gov/node/47788/psn-pdf
March 06, 2019 - Medical device-related pressure ulcers: a systematic
review and meta-analysis. … Medical device-related pressure ulcers: A systematic review and
meta-analysis. … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis … Hospital-acquired pressure ulcers are considered never events and represent a significant source of … This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries
related
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - use have been reported.( 6 ) The most common complications include aspiration and unintended local trauma … with LMAs and high peak inspiratory pressures, allowing for inspired gases to insufflate the stomach … LMA use can also lead to injuries secondary to high cuff pressure and volume during prolonged procedures … These increased intra-cuff pressures can cause a significant damage to surrounding tissues. … the pyriform sinus, which is where the recurrent laryngeal nerve enters, rendering it vulnerable to injury