-
ce.effectivehealthcare.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
74,000
2.3
Pressure Ulcers … MPSMS (2015)
Hospital-Acquired Pressure Ulcers
1,190,000
36.3
Surgical Site Infections
NHSN … wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure ulcer … [7] The AHRQ-developed pressure ulcer toolkit and falls toolkit are online.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
May 01, 2014 - Ulcer for 3 or more weeks
USUAL COGNITIVE FUNCTION
Good Questionable Impaired
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
September 01, 2014 - Adverse Events PSI OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
Pressure Ulcers … MPSMS Hospital-Acquired Pressure Ulcers
Surgical Site Infections NHSN SSIs combined for 17 procedures … Hospital-Acquired Pressure
Ulcers
53.03 62.45 0.85
VAP Ventilator-Associated
Pneumonia
1.30 2.67 … Discharges
(HCUP)
2010 PFP
Measured
HACs per
1,000
Discharges
Pressure Ulcer MPSMS Hospital-Acquired … Pressure Ulcers 1,317,211 32,750,000 40.220
Surgical Site
Infection
NHSN SSIs for 17 procedures in
-
ce.effectivehealthcare.ahrq.gov/hai/pfp/2014-final.html
January 01, 2018 - About 40 percent of the overall reduction is from adverse drug events, about 28 percent from pressure ulcers … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
74,000
2.3
Pressure Ulcers … MPSMS (2014)
Hospital-Acquired Pressure Ulcers
1,010,000
30.9
Surgical Site Infections
NHSN … wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure ulcer
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Rivard_97.pdf
April 28, 2008 - non-Federal hospitals, likelihood of a PSI event was
higher in major teaching hospitals for decubitus ulcer … our hypotheses that PSIs would be neither more nor less likely in teaching
hospitals for decubitus ulcer … Others, such as decubitus ulcers,
are likely more sensitive to nurse staffing and care. … Some indicators, such as decubitus ulcers and postoperative PE/DVT, are more sensitive to
limitations … Cautious use of
administrative data for decubitus ulcer outcome
reporting.
-
ce.effectivehealthcare.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Events
PSI
OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
Pressure Ulcers … MPSMS
Hospital-Acquired Pressure Ulcers
Surgical Site Infections
NHSN
SSIs combined for 17 … Hospital-Acquired Pressure Ulcers
53.03
62.45
0.85
VAP
Ventilator-Associated Pneumonia … Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
82,300
32,750,000
2.513
Pressure Ulcer … MPSMS
Hospital-Acquired Pressure Ulcers
1,317,211
32,750,000
40.220
Surgical Site Infection
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - hospital-acquired infections, adverse drug events, and injuries due to procedures,
as well as pressure ulcers … example,
measured adverse drug events continued to drop from 2014 to 2016, while measured pressure
ulcers … Events
PSI OB Trauma in Vaginal Delivery
(PSI 19)
With (PSI 18) and Without Instrument
Pressure Ulcer … Trauma in Vaginal Delivery
Instrument (PSI 19)
With (PSI 18) and Without 67,482 2.27
Pressure
Ulcer … With (PSI 18) and
Without Instrument
267,48 2.27 64,077 2.15 64,077 2.15
(PSI 19)
Pressure
Ulcer
-
ce.effectivehealthcare.ahrq.gov/hai/pfp/interimhac2013-ap4.html
December 01, 2014 - Adverse Events
380,000
30%
50%
15%
57,000
$3,000
.0015
$171,000,000
84
Pressure Ulcers … 1,040,500
NA
NA
$9,141,150,000
35,647
* Additional costs per HAC for Falls and Pressure Ulcers … wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure ulcer
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects.docx
April 01, 2022 - · Comfort care
· Urological/perineal procedure
· Stage 3 or greater pressure ulcer in perineal area with
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
January 01, 2019 - There are no detailed sections
for the Perinatal, Pressure Ulcer, or Surgery or Anesthesia EVENT TYPES … This was unexpected, as pressure ulcers,
like HAIs and venous thromboembolism (VTE), result in harm … TYPES, however, Mild harm was more commonly reported: a total of 68.3% (32,234 /
47,199) of Pressure Ulcers … I or stage/category II
A pressure ulcer whose most advanced stage is unknown
A mucosal ulcer without … skin or tissue involvement
An arterial or venous ulcer
A diabetic foot ulcer
Surgery/Anesthesia
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/cellulitis-one-page.docx
November 01, 2019 - –50%
· Usually associated with skin surface disruption due to recent trauma, tinea pedis, cutaneous ulcer … Patients with aquatic injuries, bites, and cellulitis associated with long-standing diabetic foot ulcers
-
ce.effectivehealthcare.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 … ( (“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “Bedsore” [tiab] OR “Bed Sores” [tiab] OR … Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH] OR “ … Costs of venous thromboembolism, catheter-associated urinary
tract infection, and pressure ulcer. … Pressure Ulcers
Exhibit D7. Surgical Site Infections
Exhibit D8.
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/aspirin-algorithm.pdf
December 14, 2015 - Affairs
Lipid Algorithm
Men and women 50-70, and all
patients with ASCVD
Does the patient a recent ulcer
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
June 29, 2016 - PSI 03 Pressure Ulcer
PSI 06 Iatrogenic
Pneumothorax
PSI 07 Central Venous
Catheter-Related
Bloodstream … Neonatal Blood
Stream Infection Rate
PDI 01 Accidental
Puncture or Laceration
Rate
PDI 02 Pressure Ulcer
-
ce.effectivehealthcare.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals/slides.html
October 01, 2014 - Walking Through the Process
Eliminate Hospital-Acquired Stage 3/4 Pressure Ulcers on the Unit … educate on science of safety, data, goals
Research the evidence-based practices that eliminate pressure ulcers … Implement teamwork tools
Provide feedback, investigate each case
Eliminate Stage 3, 4 Pressure Ulcers … Comprehensive skin assessment
Standardized pressure ulcer risk assessment
Care planning and implementation
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-wound-cleaning.pdf
March 01, 2022 - clinical trials with the explicit instructions to clean superficial wounds
and stage 1 and 2 decubitus ulcers … CHG can be applied to any superficial wound, including stage 1 and 2 decubitus ulcers, friable
skin/
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
June 04, 2018 - CLABSI - Central Line-Associated Bloodstream Infection
Falls
Obstetric
Adverse
Events
Pressure
Ulcers
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-l.pdf
September 01, 2015 - “CAUTI
“Incontinent patients
need a urinary catheter
to prevent hospital-
acquired pressure
ulcers … difficile infection, immobility (Foley is considered a "one-point
restraint"), hospital-acquired pressure ulcers
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
January 01, 2019 - Clostridioides
difficile
Infections
-37%
Falls
-5%
Obstetric
Adverse
Events
-3%
Pressure
Ulcers
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - hospital-acquired infections, adverse drug events, and injuries due to procedures,
as well as pressure ulcers … example, measured adverse
drug events continued to drop from 2014 to 2017, while measured pressure ulcers … Events
PSI OB Trauma in Vaginal Delivery
(PSI 19)
With (PSI 18) and Without Instrument
Pressure Ulcer … MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs for … Baseline
to 2014
Baseline
Normalized to
2014 Baseline
Normalized to
2014 Baseline
Pressure
Ulcer