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81. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023.pdf
    January 01, 2023 - About half (49.0%; 29,384 / 60,021) of Pressure ulcers were reported in Inpatient care areas. … Pressure Ulcers result in harm to the patient by their very nature. … This is unexpected, as pressure ulcers result in harm to the patient by their very nature. … I or stage/category II • A pressure ulcer whose most advanced stage is unknown • A mucosal ulcer without … Pressure Ulcers result in harm to the patient by their very nature.

82. Toolkit for Using the AHRQ Quality Indicators - A “How to” Guide for Improving Hospital Quality and Safety | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
    December 01, 2017 - The number of hospitalizations involving pressure ulcers increased by about 80% between 1993 and 2006 … patients may have pressure ulcers at any one time. … Include in the medical record complete documentation of any pressure ulcer found. … Pressure Ulcer Risk Assessment at Admission and Daily: Evaluate all patients for pressure ulcers and … pressure ulcer risk (using Braden Scale or other tool) upon admission and every 24 hours thereafter,

83. 4 Tk2 T2-Antibiotic Pocket Cards (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T2-Antibiotic_Pocket_Cards.pdf
    May 01, 2014 - • Use anti-MRSA antibiotic empirically for abscess or chronic ulcer meeting criteria for deep infection … Decubitus ulcer in a resident at the end of life. 12.

84. Module 2: How To Manage Change (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange.docx
    August 31, 2017 - Policies Tool 2E: Assessing Screening for Pressure Ulcer Risk Tool 2F: Assessing Pressure … Ulcer Care Planning Alert the Implementation Team Leader to be ready to discuss and decide who … will oversee administering the Pieper Pressure Ulcer Knowledge Test to staff, and who will be in charge … Policies (completed by the Implementation Team Leader) Tool 2E: Assessing Screening for Pressure Ulcer … Risk (completed by the Implementation Team Leader or designee) Tool 2F: Assessing Pressure Ulcer Care

85. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/pfp/interimhacrate2013.html
    November 01, 2015 - The estimated cost per pressure ulcer was based on a report for CMS by RTI international (Kandilov, et … Severity diagnosis-related group (MS-DRG), sex, race, and age that did NOT have a Stage III or IV pressure ulcer … ulcers. … Mortality for patients with pressure ulcer was compared to mortality among a matched set of patients, … ulcers is high compared to other HACs ( Appendix Exhibit A2 ).

86. Background for AHRQ Quality Indicators
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3b_combo_resultspresentation.pptx
    January 01, 2012 - However, Pressure Ulcers (PSI 03) occur at higher rates than the national average – this may be an area … and exclusion rules for the denominator, with any secondary ICD-10-CM diagnosis codes for pressure ulcer … and any secondary ICD-10-CM diagnosis codes for pressure ulcer stage III or IV (or unstageable). … A PSI Example: Pressure Ulcer (PSI 03) Toolkit for Using the AHRQ Quality Indicators How to Improve … Examining Observed Rates of Pressure Ulcers (PSI 03) Observed Rate 2006 2007 2008 2009 2010 2011 2012

87. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
    October 01, 2017 - On-Time Overview 5 October 2017 5 On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer … Prevention Pressure Ulcer Healing Falls Prevention Preventable Hospital and ED Visits On-Time Overview … clinicians Reports tested in clinical settings for feasibility and ease of use Large decline in pressure ulcer … incidence rate seen in Pressure Ulcer Prevention Program Evaluation October 2017 On-Time Overview 12

88. Connecticut Hospital Reduces Pressure Injuries Using AHRQ Toolkit | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/news/newsroom/case-studies/201802.html
    August 01, 2018 - Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care was central to the … hospital’s effort to prevent an estimated 114 pressure ulcers and avoid nearly $2 million in excess hospital … Saint Francis implemented the toolkit as part of an AHRQ-sponsored Hospital Pressure Ulcer Training Program … Impact Case Study Identifier: 2018-02 AHRQ Product(s): Preventing Pressure Ulcers … Toolkit Topic(s): Healthcare Costs, Outcomes, Patient Safety, Pressure Ulcers

89. Clinical Practice Guidelines Archive | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/prevention/guidelines/archive.html
    July 01, 2018 - Pressure Ulcer Prevention Clinical Guide / Quick Reference Guide Consumer Version: English / Spanish … Pressure Ulcer Treatment Clinical Guide / Quick Reference Guide Consumer Version: English / Spanish

90. Describe How a Plan or Provider Can Influence a Quality Measure | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/talkingquality/translate/labels/describe.html
    January 01, 2023 - The text included below shows what MGH is doing to reduce the rate of patients getting peptic ulcers … Overall, the rate of patients who have pressure ulcers at MGH is low. … They are also supported in their work toward pressure ulcer prevention by their local Clinical Nurse … Bed surface is a key factor in preventing pressure ulcers. … The highest percentage of pressure ulcers occur in our intensive care areas where our patients have complex

91. How To Manage Change
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
    November 20, 2014 - Relationships Unit-Based Team Staff on the unit who provide daily care to patients, including skin and pressure ulcer … family Implementation Team Interdisciplinary team charged with designing and implementing pressure ulcer

92. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
    May 01, 2017 - May 2017 On-Time Overview 5 5 On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer … Prevention Pressure Ulcer Healing Falls Prevention Preventable Hospital and ED Visits May 2017 On-Time … clinicians Reports tested in clinical settings for feasibility and ease of use Large decline in pressure ulcer … incidence rate seen in Pressure Ulcer Prevention Program Evaluation May 2017 On-Time Overview 12

93. Module 4: How To Implement the Pressure Injury Prevention Program in Your Organization (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation.docx
    August 31, 2017 - presentation Additional Related Training Resources · Staff Roles and Training for Your Pressure Ulcer … the Education Department representative to be present and ready to discuss Tool 2G: Pieper Pressure Ulcer … Education and Training (completed by the Implementation Team Leader or designee) · Tool 2G: Pieper Pressure Ulcer … Slide 35 SAY: To assess staff understanding of pressure injury prevention, Tool 2G: Pieper Pressure Ulcer … Instructor’s Note: Tool 2H: Pressure Ulcer Baseline Assessment, which is a shorter knowledge test, is

94. Recovering After Emergency Laparotomy (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/laparotomy-patient.pdf
    November 01, 2023 - While this surgery is done for many reasons, some of the most common are: ■ Hernia ■ Ulcer ■ A … Emergency Laparotomy Patient Education Guide 7 Surgery for an Ulcer [UHL-ser] An ulcer is a wound in … Surgery is done if an ulcer becomes a hole in the wall of the stomach or duodenum. … To repair the ulcer, first the surgeon may separate a strip of the fatty tissue as shown below (this … The bottom of the strip is flipped up over the ulcer to cover the hole. It’s stitched in place.

95. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - o Most advanced stage of pressure ulcer o Stage on admission o Admission skin inspection documented … o Pressure ulcer prevention intervention in place o Secondary patient morbidity • Surgery or anesthesia … Some of these explanatory statements were related to fall and pressure ulcer events, while others were … Pressure Ulcer Event Very busy environment due to COVID-19 crisis and less time and attention paid to … Pressure Ulcer Event Patient is critically ill, intubated, COVID-19 positive, in multisystem organ

96. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
    November 06, 2017 - medical record, or EMR, to make staff aware of residents at risk of adverse events such as pressure ulcers … Events SAY: There are four sets of On-Time reports to help prevent four adverse events: pressure ulcers … , pressure ulcers that are not healing appropriately, falls, and preventable hospitalizations. … when On-Time pressure ulcer prevention reports were integrated into day-to-day workflow … report is designed to identify residents at risk for the adverse event of interest (e.g., pressure ulcers

97. PMCoE PICU Expert Work Group and Leadership Team Roster (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-6-b-workgroup.pdf
    September 18, 2014 - Incidence of Hospital Acquired Serious Pressure Ulcers in PICU Patients (administrative claims) 3. … Initial Risk Assessment for Immobility-related Pressure Ulcer within 24 Hours of PICU Admission (eMeasure … Measure #2: Incidence of Hospital Acquired Serious Pressure Ulcers in PICU Patients (administrative … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … Measure #3: Initial Risk Assessment for Immobility-related Pressure Ulcer within 24 Hours of PICU Admission

98. Section 6-B, Expert Workgroup Roster and Materials (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
    September 18, 2014 - Incidence of Hospital Acquired Serious Pressure Ulcers in PICU Patients (administrative claims) 3. … Initial Risk Assessment for Immobility-related Pressure Ulcer within 24 Hours of PICU Admission (eMeasure … Measure #2: Incidence of Hospital Acquired Serious Pressure Ulcers in PICU Patients (administrative … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … Measure #3: Initial Risk Assessment for Immobility-related Pressure Ulcer within 24 Hours of PICU Admission

99. Section 6-B, PMCoE PICU Expert Workgroup and Leadership Team Roster (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-6-b-pmcoe-picu-expert-workgroup.pdf
    September 18, 2014 - Incidence of Hospital Acquired Serious Pressure Ulcers in PICU Patients (administrative claims) 3. … Initial Risk Assessment for Immobility-related Pressure Ulcer within 24 Hours of PICU Admission (eMeasure … Measure #2: Incidence of Hospital Acquired Serious Pressure Ulcers in PICU Patients (administrative … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … Measure #3: Initial Risk Assessment for Immobility-related Pressure Ulcer within 24 Hours of PICU Admission

100. Module 3: Best Practices in Pressure Injury Prevention (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices.docx
     June 12, 2018 - this module is to support your efforts to use best practices as outlined in the Preventing Pressure Ulcers … Comprehensive Skin Assessment — AHRQ Pressure Injury Prevention Program Training Webinar · Using Pressure Ulcer … Pressure Injury Prevention Program Implementation Sharing Webinar · The Power of Nutrition for Pressure Ulcer … Prevention — AHRQ Pressure Injury Prevention Program Implementation Sharing Webinar · National Pressure Ulcer … Medical device related pressure ulcers in hospitalized patients. Int Wound J 2010;7:358-65.