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61. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
    January 01, 2012 - o Wound edges. … - terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure- injury/ Staff … Washington, DC: National Pressure Ulcer 5 Tool D.4a 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 … / 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

62. Selected Best Practices and Suggestions for Improvement (pdf file)
    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.

63. Selected Best Practices and Suggestions for Improvement (pdf file)
    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.

64. Medical device-related pressure ulcers: a systematic review and meta-analysis. | PSNet
    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.

65. Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in OIG Report as Clearly Preventable or Likely Preventable by Clinical Category (pdf file)
    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

66. Generic Dashboard Data 2025 (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2025.xlsx
    January 01, 2025 - / surgical unit) 33913 47.5% Pressure Injury Labor and delivery 288 0.4% Pressure Injury … Pressure Injury Outpatient care area 592 0.8% Pressure Injury Outside area (i.e., grounds of … Injury Communication 485 2.2% Pressure Injury Data 814 3.8% Pressure Injury Environment … 6.0% Pressure Injury Other 11187 51.7% Pressure Injury Policies and Procedures 45 0.2% … Injury UNK Female Severe Harm * * Pressure Injury UNK Female Unknown Harm * * Pressure Injury UNK

67. Pressure Ulcer Prevention Toolkit (doc file)
    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

68. Psn-Pdf (pdf file)
    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

69. Physiologic Predictors of Severe Injury: Systematic Review, Evidence Summary (pdf file)
    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.

70. Psn-Pdf (pdf file)
    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.

71. Low Tidal Volume Ventilation: Introduction, Evidence, and Implementation: Slide Presentation | Agency for Healthcare Research and Quality
    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.

72. Psn-Pdf (pdf file)
    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

73. Home and Community-Based Services Quality Indicators: (pdf file)
    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

74. Intraosseous Line Extravasation in a Pediatric Trauma Patient | PSNet
    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.

75. Healthcare Cost and Utilization Project (HCUP) NASS Notes
    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

76. Psn-Pdf (pdf file)
    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.

77. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet
    psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - 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.

78. Healthcare Cost and Utilization Project (HCUP) NASS Notes
    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

79. Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. | PSNet
    psnet.ahrq.gov/issue/shift-shift-nursing-handover-interventions-associated-improved-inpatient-outcomes-falls
    July 07, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review. … injuries and medication administration errors: an integrative review. … injuries, medication administration errors). … injuries and medication administration errors: an integrative review.

80. Nothing Called Small Surgery | PSNet
    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.