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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
May 06, 2008 - have also been instrumental in the development of programs for falls risk assessment
and mitigation, pressure … ulcer risk assessment and mitigation, and a suicide risk assessment, all
of which have been hard-wired … assessments, implemented in 14
organizations, require every nurse to assess each patient’s risk for falls, pressure … ulcers, and
suicide consistently across all 14 organizations. … There has been a
36 percent reduction in the pressure ulcer rate since July 2006.
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hcup-us.ahrq.gov/db/tools/Dx_Pr_Grps_Formats.TXT
December 28, 2023 - SKN002 : Other specified inflammatory condition of skin'
'SKN003 ' = 'SKN003 : Pressure … ulcer of skin'
'SKN004 ' = 'SKN004 : Non-pressure ulcer of skin'
'SKN005
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.docx
March 01, 2017 - .
· Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.html
March 01, 2017 - Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral wounds
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hcup-us.ahrq.gov/reports/methods/2011_06.pdf
January 01, 2011 - ulcers – Stage III or IV – per 1,000 discharges of length 5 or more daysa (excluding
neonates; transfers … ulcers – Stage III or IV – per 1,000 discharges of length 5 or more days (excluding transfers;
patients … ulcers, such as cases from earlier admissions or
from other hospitals. … Ulcer
PSI 8 – Post-operative hip fractures
PSI 9 – Post-operative hemorrhage or hematoma … Ulcer
PDI 5 Pediatric: Iatrogenic Pneumothorax
PDI 8 Pediatric: Postoperative Hemorrhage or
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b1_pdi_applyingpdis.pdf
March 01, 2016 - In this example, two hypothetical hospitals (A and B) are assessing their performance on PDI 02,
Pressure … Ulcers. … signifies
better performance because fewer adverse events have occurred, in this case fewer patients
with pressure … ulcers.)
4.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b1_combo_applyingqis.pdf
March 01, 2016 - In this example, two hypothetical hospitals (A and B) are assessing their performance on PSI 03,
Pressure … Ulcers. … signifies better
performance because fewer adverse events have occurred, in this case fewer patients with
pressure … ulcers.)
4.
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/aD-Br2oTJ67FeNdHHkLtPA
A. WHO - ASSIST V3.0
IIIINTERVIEWER NTERVIEWER NTERVIEWER NTERVIEWER IDIDIDID CCCCOUNTRYOUNTRYOUNTRYOUNTRY CCCCLINICLINICLINICLINIC
PPPPATIENT ATIENT ATIENT ATIENT IDIDIDID DDDDATEATEATEATE
IIIINTRODUCTION NTRODUCTION NTRODUCTION N…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/osteoarthritis-pain-2006_appendixes.pdf
January 01, 2006 - Comparative Effectiveness Review
118
Appendix A. Pharmacokinetics, Indications and
Dosing of Included Drugs
Drug and Trade
Name
(Trade names
provided only for
drugs under
patent.)
Half-life or other
relevant
pharmacokinetic
feature
Labeled indications Dosing (oral
doses)
Dose adjustments fo…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/patient-family-centered-care-slides.html
December 01, 2017 - the Council
Welcome Video to welcome new patients to the hospital
C- Diff flyer
Brochure on Pressure … Ulcers
Noise Reduction Sleep Time Sign
Nurse Residency Program- Testimonials
Food and Quality
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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Complications
(4)
Nosocomial Infections
(4)
Patient Falls
(1)
Pressure … Ulcers
(1)
Medication Safety
(6)
Medication Errors/Preventable Adverse
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psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - While this intervention did not reduce safety incidents like pressure ulcers or falls , it did identify
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Bernard.pdf
January 01, 2004 - Nursing-related patient safety events include hip fractures and decubitus ulcers
(the remaining 2 of
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psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - is that there are four risk factors that underlie many of our hospital acquired
conditions, (i.e., pressure … ulcers and catheter associated infections, falls, and delirium).
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-reports-ig.pdf
November 30, 2013 - ulcer
Peripheral vascular
disease
Respiratory, other
nonpneumonia
Renal disease
Seizure … ulcer, fall risk, late-loss ADL index score
greater than or equal to 12 [based on RUG-III], cognitive … ulcer, and two medical conditions
(cellulitis and hypertension) would trigger Rule 2. … ulcer. … If there
is a pressure ulcer stage 2, 3, 4, or unstageable recorded
as present within 7 days of the
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/by8VJVre6h6BmadrGxaFMM
April 01, 2016 - Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: USPSTF Recommendation Statement
Aspirin Use for the Primary Prevention of Cardiovascular Disease
and Colorectal Cancer: U.S. Preventive Services Task Force
Recommendation Statement
Kirsten Bibbins-Domingo, PhD, MD, MAS, on behalf …
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html
October 01, 2014 - Reddened or darkened skin near a pressure point, or skin breakdown in those areas, can lead to a full pressure … ulcer (bed sore) if not responded to promptly.
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…