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301. Intramuscular Injections – Best Practices for Safe Vaccine Administration in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/intramuscular-injections.pdf
     June 01, 2021 - intramuscular (IM) administration is important to make sure the vaccine does its job and to avoid shoulder injury … and Health Administration (OSHA) regulations do not require you to wear gloves unless you have open wounds … Apply gentle pressure to the injection site for several seconds or longer to minimize bleeding using … For residents who take anticoagulation medications, gentle pressure may need to be applied longer to … pre-filled autoinjector (at least three doses) • H1 antihistamine (e.g., diphenhydramine/Benadryl) • Blood pressure

302. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet
     psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
     January 29, 2021 - His peak airway pressures were initially 23-25 cm H 2 O but suddenly increased to 48-52 about 30 minutes … Obesity is often associated with difficult ventilation because high airway pressures are required to … Thirty minutes into the operation the airway pressures suddenly increased from 25 to 50 cm of H 2 O and … Pneumothorax can occur in trauma patients who may have undiagnosed rib fractures. … Airway management in trauma.

303. The Magnetic Deflection | PSNet
     psnet.ahrq.gov/web-mm/magnetic-deflection
     November 18, 2016 - She was admitted to the stroke unit and received aggressive treatment to control her blood pressure. … This powerful attractive force can result in injury to a patient or health care worker from any of various … These include, among others: Direct trauma from the accelerating ferromagnetic object striking the patient … To this day, injuries continue to occur in MRI scanners around the globe from ferromagnetic objects being … modality—at times with serious, and even fatal, consequences.( 6-10 ) The only way to avoid such events and injuries

304. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851099/psn-pdf
     June 28, 2023 - and procalcitonin levels were elevated, serum creatinine was 1.5 mg/dL (consistent with acute kidney injury … when the patient is hypotensive.7,8,9 Arterial injection of drugs can cause ischemia by direct vessel injury … https://psnet.ahrq.gov//#29 https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient … Display arterial and central venous pressures on the monitor Displaying the pressure measured at the … Injection injury of an aberrant superficial radial artery requiring surgical intervention.  

305. Appendix C8: Fall Interventions Plan Sample | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt8.html
     December 01, 2017 - Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions ___ Low blood pressure … Behavior management strategies _X_ Increase assistance and surveillance    _X_ Position or pressure … Increase activities involvement    ___ Other ___________________________ _X_ Reduce risk of injury

306. Documentation and Coding for Patient Safety Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
     March 15, 2016 - PDI 02 Pressure Ulcer Rate (stage III, IV, Unstageable) Diagnosis and site of pressure ulcer must … PSI 18, PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without … X PDI 11 Postoperative Wound Dehiscence Rate X Depth of the wound dehiscence: external/superficial … X PSI 14 Postoperative Wound Dehiscence X Depth of the wound dehiscence: external/superficial vs … PSI 18 PSI 19 OB Trauma – Vaginal Delivery With Instrument OB Trauma – Vaginal Delivery Without

307. Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2011
     January 01, 2011 - Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011 Project Name Evaluation … of AHRQ's On-time Pressure Ulcer Program Principal Investigator Hurd, Donna Organization … Project Period June 2009 - January 2012 AHRQ Funding Amount $1,699,797 Summary: Pressure … Although substantial research has documented that preventing pressure ulcers and falls is possible, these … Information on pressure ulcer incidence provided by the facilities for a 12-month period and adjusted

308. Session 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess2.html
     October 01, 2014 - Additional Tools and Resources Limiting Falls that Cause Injury Residents in long-term … However, what we can do is eliminate needless falls and limit the injuries from falls that do occur. … Things about the equipment or care plan (e.g., monitor blood pressure frequently). … Things about equipment or the care plan, including: More frequent blood pressure monitoring. … Relationship between physical restraint removal and falls and injuries among nursing home residents.

309. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/860380/psn-pdf
     January 10, 2024 - The authors attributed low positive predictive value (PPV) in three of the PSIs (pressure injury, falls

310. Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. | PSNet
     psnet.ahrq.gov/issue/taking-heat-or-taking-temperature-qualitative-study-large-scale-exercise-seeking-measure
     November 02, 2016 - measurement program in the United Kingdom, the NHS Safety Thermometer, which measured incidence of pressure … June 28, 2017 Towards international consensus on patient harm: perspectives on pressure … injury policy. … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … See More About The Topic Hospitals Physicians Medicine Nosocomial Infections Pressure

311. Table 16A: Outcome Indicators by County Socioeconomic Status | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
     December 01, 2012 - 9,257 6,892 Composite: ACSC Overall 17,570 24,934 20,620 17,662 23,518 18,337 Pressure … 10,435 7,884 Composite: ACSC Overall 19,406 27,524 22,656 19,821 25,958 20,278 Pressure … 5,382 4,110 Composite: ACSC Overall 12,450 16,541 14,919 11,150 15,491 12,897 Pressure … 3,777 3,248 Composite: ACSC Overall 5,094 6,963 6,484 4,695 6,310 5,297 Pressure … 8,215 6,780 Composite: ACSC Overall 17,579 23,121 20,378 17,055 21,295 18,297 Pressure

312. DXCCSR-vs-Beta-CCS-Comparison (pdf file)
     hcup-us.ahrq.gov/toolssoftware/ccsr/DXCCSR-vs-Beta-CCS-Comparison.pdf
     January 01, 2020 - 199 Chronic ulcer of skin 3 SKN003 – Pressure ulcer of skin SKN004 – Non-pressure ulcer of skin 200 … injury, IE INJ047 – Internal organ injury, SE INJ073 – Injury, sequela 235 Open wounds of head; … neck; and trunk 11 INJ011 – Open wounds of head and neck, IE INJ048 – Open wounds of head and neck … , SE INJ013 – Open wounds of trunk, IE INJ050 – Open wounds of trunk, SE INJ073 – Injury, sequela … 236 Open wounds of extremities 7 INJ012 – Open wounds to limbs, IE INJ049 – Open wounds to limbs,

313. Examples of Patient Harm Related to Invasive Devices | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section3.html
     October 01, 2015 - Teamwork and Communication Definitions and Tools Several examples of severe patient injury … Paraplegia (inability to walk) Ultimately, the patient underwent back surgery to decompress the pressure … The virulent organism caused a severe infection and irreversible injury to the patient. … She was found to have a fever of 102 °F, and her blood pressure dropped to 90 systolic.

314. C1 Prioritization Matrix (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
     June 02, 2025 - Patient Safety PSI 03 Pressure Ulcer   1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y PSI 06 Iatrogenic … 13 Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … Accidental Puncture or Laceration 3.2 3.3 1 $22,629 $ 22,629 Y 4 3 7 Y N Y Y Y Obstetric PSI 17 Birth Trauma-Injury … to Neonate   0.0 0.1 0 $88,000 $ - 0 N 2 3 9 Y Y Y Y Y PSI 18 Obstetric Trauma-Vaginal Delivery … Postoperative Sepsis Rate 0.0 16.2 0 $117,815 $ - 0 N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

315. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74864/psn-pdf
     February 23, 2022 - patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic https://psnet.ahrq.gov/issue/learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence

316. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet
     psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
     March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause … reviews findings of the subsequent root cause analysis , which determined training weaknesses, time pressures … , and distractions within the team due to the chaotic nature of trauma care . … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries.

317. Long-term Care Resources | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
     November 01, 2021 - Nursing Homes: On-Time Prevention End of Life Care Home and Community-based Services Falls and Injury … Long-Term Care Facilities Multiple Chronic Conditions Omissions of Care in Nursing Homes Pressure

318. AHRQ Patient Safety Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/PS-tools-2024.pdf
     January 01, 2024 - Web: ahrq.gov/goinghomeguide/ Pressure Ulcers Preventing Pressure Ulcers: A Toolkit for Improving … Web: ahrq.gov/pressureulcertoolkit The Pressure Injury Prevention in Hospitals Training Program supports … the training of hospital staff on how to implement AHRQ’s Preventing Pressure Ulcers in Hospitals … injury prevention. … approaches to design that target six areas of safety: infections, falls, medication errors, security, injuries

319. The wicked problem of patient misidentification: how could the technological revolution help address patient safety? | PSNet
     psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
     July 10, 2024 - September 27, 2016 Towards international consensus on patient harm: perspectives on pressure … injury policy. … August 7, 2019 Medical device-related pressure ulcers: a systematic review and meta-analysis

320. AHRQ Safety Program for MRSA Prevention
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/062-protocol-training-decolonization-with-chg.pptx
     October 01, 2024 - Superficial pressure injuries (stages 1 and 2) CHG should also be applied over sutured or stapled wounds … Clean wound carefully with CHG. … Apply CHG with firm pressure, unless the wound is over a bony prominence. … Using the CHG on superficial wounds, and stage 1 and 2 pressure injuries. … Refer to the slides on Wound Care.