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381. Evaluation of AHRQ’s On-Time Pressure Ulcer Program - 2012 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2012
     January 01, 2012 - Evaluation of AHRQ’s On-Time Pressure Ulcer Program - 2012 Project Name Evaluation … of AHRQ's On-time Pressure Ulcer Program Principal Investigator Hurd, Donna Organization … Although substantial research has documented that preventing pressure ulcers and falls is possible, these … In response, AHRQ funded a rigorous evaluation of the On-Time Pressure Ulcer program. … A training curriculum for the On-Time Pressure Ulcer program was developed and tested.

382. Declines in Hospital-Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf
     January 01, 2019 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Clostridioides difficile Infections -37% Falls -5% Obstetric Adverse Events -5% Pressure

383. Declines in Hospital-Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
     January 01, 2019 - Conditions National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … CLABSI+ -6% Clostridioides difficile Infections -37% Falls -5% Obstetric Adverse Events -3% Pressure

384. Outcome Indicators for the HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find4.html
     December 01, 2012 - All but two of the indicators (Pressure Ulcer and Injurious Falls) build on existing AHRQ Prevention … Pressure Ulcer. Injurious Falls.

385. Harm Free Care. | PSNet
     psnet.ahrq.gov/issue/harm-free-care
     April 15, 2020 - This initiative seeks to reduce four key sources of harm in hospitals: pressure ulcers, falls, catheter-associated … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.

386. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
     November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s) present … , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … 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. … Ostomy Wound Manage. 2016 Nov;62(11):30-8. 65 Mendizabal A, Thibault DP, Willis AW.

387. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
     November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s) present … , Closed"[Mesh] OR "Craniocerebral Trauma"[Mesh] OR "Cerebrovascular Trauma"[Mesh] OR "Cerebrovascular … 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. … Ostomy Wound Manage. 2016 Nov;62(11):30-8. 65 Mendizabal A, Thibault DP, Willis AW.

388. HCUPnet Methodology – HCUPnet Data Tools
     datatools.ahrq.gov/hcupnet/methodology/
     January 01, 2023 - throat ERCP, Endoscopic retrograde cholangiopancreatography GI, Gastrointestinal ICP, Intracranial pressure … ; internal injury of thorax, abdomen, and pelvis; open wound of the head, neck, trunk, upper limb, and … ICD-10-CM Codes for injuries are identified with the following Clinical Classification Software Refined … – Internal organ injury, initial encounter INJ011 – Open wounds of head and neck, initial encounter … INJ012 – Open wounds to limbs, initial encounter INJ013 – Open wounds of trunk, initial encounter

389. NICU Family Information Packet, Appendix B, Ostomy Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-ostomy.pdf
     June 02, 2025 - anchoring elements to bond the epidermis to the underlying dermis, so skin is more susceptible to friction injury … ■ Peristomal skin must be protected from mechanical trauma due to use of aggressive adhesives, improper … ■ Vent frequently to prevent gas pressure from compromising the seal.

390. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
     April 01, 2009 - pubmed/8333382 * PICCs Can Cause Complications In retrospective series, complications included: Wound … vessel wall, increasing chance of breakage on removal Small syringe used for flushing creates higher pressure … increased stress on catheter * Recommendations for Prevention Avoid flushing PICCs under high pressure … has become increasingly prevalent, including in pediatric inpatients PICC complications include: Injury … fractures Caregivers should be warned against flushing PICCs with small-volume syringes or with too much pressure

391. Delays in diagnosis, treatment, and surgery: root causes, actions taken, and recommendations for healthcare improvement. | PSNet
     psnet.ahrq.gov/issue/delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations
     March 25, 2020 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … injuries. … March 18, 2020 Applying modern error theory to the problem of missed injuries in trauma

392. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
     October 01, 2015 - MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse Events PSI (2013) 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.

393. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
     June 02, 2025 - Postoperative Sepsis 12.7 11.7 15 $49,215 $ 738,225 N 9 7 3 Y Y Y Y Y PSI 14 Postoperative Wound … - Injury to Neonate 0.0 0.1 0 $88,000 $ - N 2 3 9 Y Y Y Y Y PSI 18 Obstetric … Trauma-Vaginal Delivery With Instrument 134.8 135.1 17 $90,000 $ 1,530,000 N 2 3 8 Y Y … Y Y Y PSI 19 Obstetric Trauma-Vaginal Delivery Without Instrument 17.0 17.9 5 $96,000 $ … Rate 0.0 16.2 0 $117,815 $ - N 9 10 10 Y Y Y Y Y PDI 11 Postoperative Wound

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/864865/psn-pdf
     March 20, 2024 - demands during the crisis to affect falls, medication safety, healthcare associated infections, and pressure … injuries.

395. Patient safety indicators during the initial COVID-19 pandemic surge in the United States. | PSNet
     psnet.ahrq.gov/issue/patient-safety-indicators-during-initial-covid-19-pandemic-surge-united-states
     August 03, 2022 - September 1, 2021 Learning during crisis: the impact of COVID-19 on hospital-acquired pressure … injury incidence. … About The Topic Hospitals Public Health Infectious Diseases Medical Complications Pressure

396. The impact of the use of employee functional flexibility on patient safety. | PSNet
     psnet.ahrq.gov/issue/impact-use-employee-functional-flexibility-patient-safety
     January 12, 2022 - examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure … Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure … Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … injuries.

397. Table 14A: Outcome Indicators by County Supply of Health Care Providers | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab14.html
     February 01, 2023 - 7,561 7,177 Composite: ACSC Overall 19,494 19,068 22,370 17,903 19,831 18,937 Pressure … 8,666 8,172 Composite: ACSC Overall 21,480 21,331 24,806 19,795 22,008 20,929 Pressure … 4,449 4,235 Composite: ACSC Overall 13,871 12,234 15,225 12,474 13,703 13,045 Pressure … 3,525 3,189 Composite: ACSC Overall 5,684 5,096 5,763 5,286 5,764 5,235 Pressure … 10,552 Composite: ACSC Overall 25,931 27,847 34,209 23,478 26,582 26,462 Pressure

398. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - ti])) OR iatrogenesis [ti] OR iatrogenic [ti] OR ((medical [ti] OR treatment [ti] OR care [ti]) AND (injury … [ti] OR injuries [ti])) OR mishap* [ti] OR (root [ti] AND cause* [ti]) OR (failure* [ti] AND mode* [ … reducing [ab] OR reduction [ab] OR aged [mh] OR elderly OR geriatric)) OR Decubitus Ulcer [mh] OR ((pressure

399. An Easily Forgotten Tube | PSNet
     psnet.ahrq.gov/web-mm/easily-forgotten-tube
     June 01, 2016 - national guidelines, including those from the American College of Gastroenterology ( 7 ), the Welsh Wound … the past year; sensitivity or allergies to any of the materials used in the device; rectal or anal injury … An FMS device should not be used for a mobile patient as movement may lead to pressure on the tubing, … An FMS is unsuitable for spinal cord injury patients due to the high risk of autonomic dysreflexia that … Wounds UK. 2005;1:3:110-114. [Available at] 7.

400. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/hac-rates_2019.html
     July 01, 2020 - Description: National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries … Pressure ulcers: 6% increase. Surgical site infections: 8% increase.