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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.pdf
July 01, 2016 - We record onset day,
stage, and surface area of each pressure ulcer during wound rounds. … ulcer healing and you
will be able to identify wounds suspected of infection. … Pressure Injury Alliance’s Prevention and Treatment of Pressure Ulcers
Guidelines
c. Wound, Ostomy … X X X X
Wound rounds Multidisciplinary team weekly review
of residents with pressure ulcers. … Rounds
Report and Pressure Ulcers at Risk for Delayed Healing with wound rounds.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-handouts.docx
July 01, 2016 - We record onset day, stage, and surface area of each pressure ulcer during wound rounds. … ulcer healing and you will be able to identify wounds suspected of infection. … Injury Alliance’s Prevention and Treatment of Pressure Ulcers Guidelines
c. … Wound, Ostomy, and Continence Nurses Society (WOCN) Pressure Ulcer Guidelines
d. … Ulcer Report
Pressure Ulcers At Risk for Delayed Healing
Weekly Wound Rounds Report
Weekly Pressure
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www.ahrq.gov/hai/pfp/hacrate2013.html
January 01, 2018 - 2
In 2010 an HHS Office of the Inspector General (OIG) team identified the rate of harm—that is, injuries … The estimate for deaths associated with pressure ulcers was based primarily on the paper by Zhan and … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … This estimate is based on analysis of data from HCUP identifying injuries in 7.45 million hospital discharge … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - In hospitals, falls with injuries can lead to other adverse outcomes including pressure injuries or … One study found that providing patients at risk for falls with Smart Socks , which contain pressure … Another example is the CDC’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative , … no injury. … injury to that person and their psyche.
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psnet.ahrq.gov/issue/contributing-factors-pediatric-ambulatory-diagnostic-process-errors-project-redde
November 30, 2022 - Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and … included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure … August 9, 2011
Delayed or missed diagnosis of cervical spine injuries.
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - Multiple therapies were initiated to reduce the intracranial pressure and swelling, including intubation … The "Lund protocol," derived in patients with elevated ICP in the setting of head trauma, assumes that … Continuous recording and control of ventricular fluid pressure in neurosurgical practice. … Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am. 1995;6:761-773. … Hyperventilation in head injury: a review. Chest. 2005;127:1812-1827. [go to PubMed] 5.
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psnet.ahrq.gov/issue/fall-prevention-hospitals-training-program
May 01, 2017 - July 23, 2019
Pressure Injury Prevention in Hospitals Training Program.
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psnet.ahrq.gov/issue/safety-climate-associated-adverse-events-nursing-homes-national-va-study
September 08, 2021 - The survey found that supervisor commitment to safety was associated with lower rates of major injuries … from falls and catheter use, and that environmental safety was associated with lower rates of pressure … ulcers, major injuries from falls, and catheter use.
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psnet.ahrq.gov/issue/using-learning-system-approach-improve-safety-prone-position-ventilation-patients
January 10, 2024 - Issues identified included medical device-related pressure injuries and device dislodgement, concerns … March 7, 2018
Information flow during pediatric trauma care transitions: things falling … 2019
Work system barriers and facilitators in inpatient care transitions of pediatric trauma … May 18, 2022
Error reduction in trauma care: lessons from an anonymized, national, multicenter
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psnet.ahrq.gov/issue/instruments-and-warning-signs-identifying-and-evaluating-frequency-adverse-events
July 20, 2022 - Common adverse events impacting this population include adverse drug events, delirium , malnutrition, pressure … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
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www.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Catheters
Falls
MPSMS
In-Hospital Patient Falls
Obstetric Adverse Events
PSI
OB Trauma … Pressure Ulcers
Surgical Site Infections
NHSN
SSIs combined for 17 procedures based on CDC … The national number of adverse events captured by PSIs 18 and 19 on obstetric injury , and the national … Ulcers
Hospital-Acquired Pressure Ulcers
53.03
62.45
0.85
VAP
Ventilator-Associated … In-Hospital Patient Falls
262,317
32,750,000
8.010
Obstetric Adverse Events
PSI
OB Trauma
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - which Brennan and colleagues defined in the Harvard Medical Practice Study in New York State as “an injury … Thoracic Surgeons offers patient safety indicators for adult cardiac surgery, such as deep sternal wound … injuries) and hospital acquired infections (CLABSI, CAUTI). … dehiscence, and obstetric trauma. … deaths due to health care-associated venous thromboembolism, sepsis, or patient falls; in-hospital pressure
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psnet.ahrq.gov/issue/health-care-management-during-covid-19-insights-complexity-science
July 22, 2020 - October 26, 2022
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
January 01, 2006 - Hospitals
►Moving, Transferring, or Lifting Residents
►Medication errors
►Falls
►Pressure ulcers
►Sanitation … Patient Safety Culture in Nursing Homes
• Safety culture influences staff as well as residents
► Overall injury
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psnet.ahrq.gov/issue/effects-harm-events-30-day-readmission-surgical-patients
July 31, 2019 - The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%) … Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … injuries.
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www.ahrq.gov/hai/pfp/interimhacrate2013.html
November 01, 2015 - 2
In 2010 an HHS Office of the Inspector General (OIG) team identified the rate of harm—that is, injuries … The estimate for deaths associated with pressure ulcers was based primarily on the paper by Zhan and … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … This estimate is based on analysis of data from HCUP identifying injuries in 7.45 million hospital discharge … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/healthy-lifestyle-and-physical-activity-for-cvd-prevention-adults-without-known-risk-factors-behavioral-counseling
June 04, 2020 - Abbreviations: BP=blood pressure; BMI=body mass index; CVD=cardiovascular disease; yr=year. … activity, and reduce sedentary behavior improve intermediate outcomes associated with CVD (g., blood pressure … *CVD risk factors include hypertension or elevated blood pressure, dyslipidemia or elevated lipid levels … intervention (e.g., nutritional deficiencies, disordered eating, symptoms of anxiety, musculoskeletal injuries … † Persons with known traditional CVD risk factors (i.e., hypertension or elevated blood pressure,
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-erepguide.pdf
February 10, 2014 - Healing
Weekly Wound Rounds Report
Weekly Pressure Ulcer Treatment Summary Report
Pressure … home chains, and wound centers. … Injury Alliance. … The wound nurse, wound
physician, and other disciplines attending wound rounds can see
quickly which … Treatments
Wound Cleanser.
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psnet.ahrq.gov/issue/exploring-nursing-sensitive-events-home-healthcare-national-multicenter-cohort-study-using
August 05, 2020 - The most common types of nursing-sensitive events were falls , pressure injuries, healthcare-associated … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/healthy-diet-and-physical-activity-counseling-adults-with-high-risk-of-cvd
September 13, 2018 - activity for cardiovascular disease (CVD) prevention among adults with hypertension, elevated blood pressure … e.g., morbidity and mortality) in adults with known CVD risk factors (hypertension or elevated blood pressure … glucose, or body mass index) in adults with known CVD risk factors (hypertension or elevated blood pressure … What is the relationship between intermediate outcomes (e.g., blood pressure, lipid levels, blood glucose … Adverse outcomes
Harms requiring medical attention (e.g., nutritional deficiency, musculoskeletal injury