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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 3 Tools
3A: Pressure Ulcer … If a skin disruption is found, the type of skin injury will need to be identified. … Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … A wound/ostomy nurse consult revealed he has a slightly pink coccyx area (base of spinal column).
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - hospital mattress.7,8-11
o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in
hospitalised patients. Int Wound J 2010;7:358-65.
7.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4b_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - hospital mattress.7,8-11
o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in
hospitalised patients. Int Wound J 2010;7:358-65.
7.
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psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis
March 10, 2021 - This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related … injury policy. … injuries and medication administration errors: an integrative review. … June 9, 2021
Root cause analysis for hospital-acquired pressure injury. … injury policy.
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pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - and agitation secondary to benzodiazepine led
to patient pulling urinary catheter with resultant injury … brace
• Skin excoriation on buttocks
Fall associated with patient care
• Fall from bed with minor injuries … (elbow, knees, and small skin tear)
Device trauma or malfunction
• Clotted arteriovenous shunt (dialysis … access device)
• Trauma due to multiple failed Foley catheter insertions
Edema or volume overload
• … erythema on right thigh
Surgical Site Infection (SSI)
• Superficial infection that developed on existing wound
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psnet.ahrq.gov/node/73462/psn-pdf
July 07, 2021 - injuries. … injuries. … Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. … https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury
https://psnet.ahrq.gov … /root-cause-analysis
https://psnet.ahrq.gov/primer/root-cause-analysis
https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
June 02, 2025 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 5 Tools
Action Plan Tool … to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices
Tool 5C: Assessing Comprehensive … Assessment
Tool 5D: Assessing Standardized Risk Assessment
Tool 5E: Assessing Care Planning
AHRQ Pressure … stakeholders and staff
Root cause analysis is conducted for each fall with at least moderate level of injury … admission nursing assessment, subsequent nursing progress notes, or any notes specifically documenting pressure
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psnet.ahrq.gov/node/854638/psn-pdf
October 18, 2023 - Early identification and evaluation of severe pressure
injuries.
October 18, 2023
Quick Safety. … https://psnet.ahrq.gov/issue/early-identification-and-evaluation-severe-pressure-injuries
Pressure injuries … https://psnet.ahrq.gov/issue/early-identification-and-evaluation-severe-pressure-injuries
https://psnet.ahrq.gov … /issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis
https://psnet.ahrq.gov … /issue/pressure-injury-prevention-hospitals-training-program
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psnet.ahrq.gov/node/60857/psn-pdf
August 26, 2020 - Arguably the most severe complication of digital tourniquets, ischemic injuries, have two
principal … Excessive tourniquet pressures cause ischemic
injury by vascular compression, which can lead to intimal … First, the use of a self-
made tourniquet likely applied excessive pressure, which caused vascular injury … J Orthop Trauma. 2010 Jun;24(6):387–8.
3. Smith IM, Austin OMB, Knight SL. … J Trauma. 2006 Dec;61(6):1415–8.
15.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-205-predictors-trauma-care-evidence-summary.pdf
April 01, 2018 - e.g., a crush injury or
amputation), but other injuries require
additional assessment. … in trauma patients, but that
many patients with serious injuries will have normal
physiologic measures … Systolic blood
pressure criteria in the National Trauma Triage Protocol for
geriatric trauma: 110 is … Shock index as a marker
for significant injury in trauma patients. … Coma Scale, Age, and Systolic Blood Pressure score.
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www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-slides.html
February 01, 2025 - Pressure limited. … Slide 22: LTVV in ARDS Large V t and the high pressures it generates were harmful 3,4 LTVV became the … to measure transpulmonary pressures clinically). … Trauma. Noncardiogenic shock. Multiple transfusions. Cardiopulmonary bypass. … Trauma. Pancreatitis. Post-circulatory arrest. Multiple transfusions. Severe burns.
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psnet.ahrq.gov/node/45202/psn-pdf
October 08, 2016 - Towards international consensus on patient harm:
perspectives on pressure injury policy. … Towards international consensus on patient harm:
perspectives on pressure injury policy. … https://psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury … https://psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-policy … https://psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-policy
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hcup-us.ahrq.gov/db/vars/i10_injury/nassnote.jsp
August 10, 2019 - categories align with the 2020 ICD-10-CM Injury Diagnosis Framework for Categorizing Injuries by Body … T07-T34 series: Injuries involving multiple body regions; injury of unspecified body region; effects … Data Year 2015 ICD-10-CM Diagnosis Codes Used to Identify Injury Discharges
Records with injuries are … injury of thorax, abdomen, and pelvis; open wound of the head, neck, trunk, upper limb, and lower limb … ; injury to nerves and spinal cord; traumatic complications and unspecified injuries, initial or subsequent
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2024.xlsx
January 01, 2024 - Documented within 24 hours of admission 0.9% 35
Stage/Category IV Unknown * *
Suspected Deep Tissue Injury … Documented within 24 hours of admission 71.0% 2,897
Suspected Deep Tissue Injury No risk assessment … documented * *
Suspected Deep Tissue Injury Not on admission, but documented after discovery or advancement … of pressure ulcer 78.6% 11
Suspected Deep Tissue Injury Not on admission, but documented before discovery … or advancement of pressure ulcer * *
Suspected Deep Tissue Injury Unknown 69.4% 1,111
Unstageable
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - Her wounds led to significant blood loss. … arterial blood pressure. 23 Elevated compartment pressure leads initially to venous congestion, then … transferred to the OR for surgical exploration, debridement, and possible closure of her traumatic wounds … Injury . 2017;48:S22–S25. [ Available at ]
Shuler MS, Reisman WM, Kinsey TL, et al. … Injury . 1994;25(6):379–81. [ Free full text ]
Günal I, Köse N, Gürer D.
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - She had hypotension, with
blood pressure around 80s/50s. … A pressure dressing and splint were applied. … In the
meantime, the patient continued to bleed from her right ankle wound. … Retrohepatic IVC and
hepatic vein injuries are amongst the most fatal injuries encountered in trauma … Gunshot wounds to the liver: no longer a mandatory
operation.
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hcup-us.ahrq.gov/db/vars/i10_multinjury/nassnote.jsp
August 10, 2019 - categories align with the 2020 ICD-10-CM Injury Diagnosis Framework for Categorizing Injuries by Body … T07-T34 series: Injuries involving multiple body regions; injury of unspecified body region; effects … Data Year 2015 ICD-10-CM Diagnosis Codes Used to Identify Injury Discharges
Records with injuries are … injury of thorax, abdomen, and pelvis; open wound of the head, neck, trunk, upper limb, and lower limb … ; injury to nerves and spinal cord; traumatic complications and unspecified injuries, initial or subsequent
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qualityindicators.ahrq.gov/Downloads/Resources/Publications/2012/Appendix_1A_Details_of_literature_review.pdf
January 01, 2012 - Inflicted by Others 10
Medication Errors 17
Pressure Ulcer 20
Accidental Injuries Potentially … for location, depth and
stage, size, and wound bed (e.g., necrotic tissue, exudate, wound edges for … "Spinal cord injury and pressure ulcers." Nurs Clin North Am 40(2): 337-347. … Other Injuries
• One review examined prevention of injury in people with intellectual disabilities. … Potentially Due to Neglect
“wounds and injuries”[MeSH] OR “accidental injury”[MeSH]
“accidental falls
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - injury to the skin and soft tissues, and ischemic injury resulting in digital necrosis. … Arguably the most severe complication of digital tourniquets, ischemic injuries, have two principal causes … Excessive tourniquet pressures cause ischemic injury by vascular compression, which can lead to intimal … First, the use of a self-made tourniquet likely applied excessive pressure, which caused vascular injury … J Orthop Trauma. 2010 Jun;24(6):387–8.
Smith IM, Austin OMB, Knight SL.
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hcup-us.ahrq.gov/toolssoftware/ccsr/DXCCSR-ChangeLog-v20191-v20201.xlsx
October 01, 2019 - Pressure-induced deep tissue damage of left elbow
SKN003 Pressure ulcer of skin L89106 Pressure-induced … Pressure ulcer of skin L89216 Pressure-induced deep tissue damage of right hip
SKN003 Pressure ulcer … Pressure-induced deep tissue damage of unspecified buttock
SKN003 Pressure ulcer of skin L89316 Pressure-induced … Pressure ulcer of skin L89606 Pressure-induced deep tissue damage of unspecified heel
SKN003 Pressure … L89626 Pressure-induced deep tissue damage of left heel
SKN003 Pressure ulcer of skin L89816 Pressure-induced