-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4g_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system
depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate
poisoning, … expansion exercises with
children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory
failure in children: a concise review
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - o Decreased central nervous system input (head injury, ingestion of central nervous system
depressant … o Peripheral nerve/neuromuscular junction (spinal cord injury, organophosphate/carbamate
poisoning, … expansion exercises with
children, such as incentive spirometry, deep breathing, intermittent positive-pressure … breathing, and continuous positive airway pressure. … Noninvasive positive pressure ventilation for acute respiratory
failure in children: a concise review
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressureulcertoolkit/putoolssect7.docx
February 16, 2011 - Pressure ulcers are sterile wounds.
36. … Pressure ulcers are sterile wounds.
False
36. … If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … unit staff for pressure ulcer practice
Certified Wound Care Nurse
· Assesses wounds, does complex
-
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
-
psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - 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 … blood pressure. … 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.
-
psnet.ahrq.gov/issue/using-community-detection-techniques-identify-themes-covid-19-related-patient-safety-event
July 29, 2020 - (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors , pressure … June 16, 2021
Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
January 01, 2010 - Smith (2)
Because of his immobility, he develops a pressure ulcer on his sacrum. … Few days later, he develops fever and his blood pressure drops. … Incontinent with open sacral/perineal wounds
Consult with wound care
End of life/hospice
Be sure it … Trauma)
Admitting service (e.g. … Protocolized care for trauma
Incontinence without open sacral or perineal wounds
Pre-operative
-
psnet.ahrq.gov/issue/applying-hfmea-prevent-chemotherapy-errors
September 27, 2017 - Citation
Related Resources From the Same Author(s)
Surgeon commitment to trauma … care decreases missed injuries. … March 9, 2009
System approach to prevent common bile duct injury and enhance performance … May 22, 2013
Interactive effects of nurse-experienced time pressure and burnout on patient
-
psnet.ahrq.gov/node/45251/psn-pdf
August 24, 2016 - Reporting on
a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery … center, this news
article describes how factors such as production pressure and insufficient assessment … advancing-patient-safety-cataract-surgery-betsy-lehman-center-expert-panel-report
https://psnet.ahrq.gov/web-mm/production-pressures
-
digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2010
January 01, 2010 - Evaluation of AHRQ's On-time Pressure Ulcer Program - 2010
Project Name
Evaluation … of AHRQ's On-time Pressure Ulcer Program
Principal Investigator
Hurd, Donna
Organization … Substantial research has documented that prevention of pressure ulcers and falls is possible, yet these … Many initiatives to improve quality of pressure ulcer care in nursing homes have been undertaken in the … last decade, including the Agency for Healthcare Research and Quality (AHRQ) funded On-Time Pressure
-
psnet.ahrq.gov/issue/differences-reporting-care-related-patient-injuries-existing-reporting-systems
December 12, 2018 - Commentary
Differences in the reporting of care-related patient injuries to existing … Differences in the reporting of care-related patient injuries to existing reporting systems. … Differences in the reporting of care-related patient injuries to existing reporting systems. … Related Resources From the Same Author(s)
Success in hospital-acquired pressure
-
psnet.ahrq.gov/issue/error-reduction-trauma-care-lessons-anonymized-national-multicenter-mortality-reporting
March 24, 2021 - J Trauma Acute Care Surg. 2022;92(3):473-480. doi:10.1097/ta.0000000000003485. … J Trauma Acute Care Surg . 2022; 92 (3) :473-480 . … J Trauma Acute Care Surg. 2022;92(3):473-480. doi:10.1097/ta.0000000000003485. … June 30, 2021
Zero preventable deaths after traumatic injury: an achievable goal. … More
Related Resources
WebM&M Cases
Under Pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhospitalvisits-funcspecs_0.pdf
August 01, 2017 - Ulcer
Vendor determined
or Wound
Assessment
Pressure ulcer Stage II,
III, IV, or unstageable. … IF wound assessment date ≤7 days of
report date AND at least one pressure
ulcer with ulcer stage = … then display X in Wound
• Infected wound or decubitus ulcer
• Jaundice
• Rash
10 Injury: Fall … X in Injury:
11 Injury: Non-
Fall Related
Transfer
Note
•
•
Major injury
Minor injury
IF … Chest pain/angina
Dizzy/lightheaded
Non-Fall-Related Injury
Major injury
Minor injury
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-electronic-reports.pdf
February 10, 2014 - This report is helpful for nursing home staff and
wound nurses to promote early identification of pressure … These details are available at the time the pressure ulcer is being assessed during wound rounds
or … For example,
the Pressure Ulcers At Risk for Delayed Healing Report; Weekly Wound Rounds Report; … DON or ADON, Nurse Manager, Wound Nurse, QI
Director
Root Cause Analysis for New Pressure Ulcers … Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury
Alliance
-
www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
October 27, 2014 - MPSMS
(2013)
In-Hospital Patient
Falls
240,000 7.2
Obstetric
Adverse
Events
PSI (2012) OB Trauma … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. … Eliminating birth trauma at Ascencion Health.
-
digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program
January 01, 2023 - Evaluation of AHRQ's On-time Pressure Ulcer Program
Project Description … In response to this need, AHRQ funded a rigorous evaluation of the On-Time Pressure Ulcer program. … The objects of the project were to:
Evaluate the effect of the On-Time Pressure Ulcer program by … A training curriculum for the On-Time Pressure Ulcer program was developed and tested. … Evaluation of AHRQ’s On-Time Pressure Ulcer Program - 2012
Evaluation of AHRQ's On-time Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14b.html
February 01, 2023 - 8,183
6,565
8,085
6,602
Composite: ACSC Overall
21,956
16,765
21,455
17,068
Pressure … 9,399
7,435
9,300
7,477
Composite: ACSC Overall
24,337
18,495
23,801
18,856
Pressure … 4,604
4,083
4,637
4,018
Composite: ACSC Overall
14,949
11,832
14,796
11,790
Pressure … 3,512
3,245
3,653
3,037
Composite: ACSC Overall
5,797
5,112
5,808
5,048
Pressure … 7,096
6,863
7,055
6,912
Composite: ACSC Overall
19,429
17,580
19,054
18,048
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16b.html
February 01, 2023 - 6,179
9,131
7,304
7,421
Composite: ACSC Overall
16,590
23,347
19,328
18,994
Pressure … 6,990
10,438
8,363
8,406
Composite: ACSC Overall
18,160
25,955
21,393
21,016
Pressure … 3,968
4,959
4,286
4,448
Composite: ACSC Overall
12,312
15,022
13,443
12,894
Pressure … 3,146
3,780
3,577
3,068
Composite: ACSC Overall
5,039
6,194
5,874
4,811
Pressure … 13,732
10,164
12,022
Composite: ACSC Overall
22,116
33,392
25,404
30,079
Pressure
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15b.html
February 01, 2023 - 8,040
6,786
7,702
6,976
Composite: ACSC Overall
21,669
17,341
20,812
17,696
Pressure … 9,170
7,724
8,821
7,929
Composite: ACSC Overall
23,918
19,140
23,031
19,550
Pressure … 4,402
4,279
4,338
4,320
Composite: ACSC Overall
14,429
12,531
14,135
12,525
Pressure … 3,398
3,382
3,385
3,397
Composite: ACSC Overall
5,517
5,450
5,449
5,532
Pressure … 7,202
6,782
7,004
6,990
Composite: ACSC Overall
19,879
17,354
19,092
18,022
Pressure
-
psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - The most common complications of ECMO are bleeding from cannulation sites (15-20%) or surgical wounds … Brain injury during venovenous extracorporeal membrane oxygenation. … Pressures – does the pump produce a pressure adequate for flow? What are the pressure trends? … Pressures are monitored before (pre-pump pressure), between pump and oxygenator (pre-oxygenator), and … January 11, 2017
Evaluation of wound photography for remote postoperative assessment