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101. 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 - ulcers, pressure ulcers that are not healing appropriately, falls, and preventable hospitalizations … For example:  Pressure Ulcer Prevention has been pilot tested in more than 50 nursing homes across … the country; several studies have shown significant reductions in pressure ulcer incidence rates … when On-Time pressure ulcer prevention reports were integrated into day-to-day workflow …  Pressure Ulcer Healing, Falls, and Avoidable Hospitalization reports and worksheets have been

102. 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 - ulcer 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

103. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/index.html
     March 01, 2024 - Ulcers in Hospitals Re-Engineered Discharge Toolkit QI Toolkit Venous Thromboembolism … Preventing Pressure Ulcers in Hospitals is a toolkit that assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … Hospitals Training Program supports the training of hospital staff on how to implement AHRQ's Preventing Pressure … Ulcers in Hospitals Toolkit.

104. Best Practices in Pressure Injury Prevention
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices_slides.pptx
     November 20, 2014 - documentation forms Lacking ways to empower staff to report abnormal skin findings: Consider using Tool 3C: Pressure … Ulcer Identification Pocket Pad. 11 ID Pocket Pad Tool 3C 12 Practice Insight Or note location … 27 Practice Insight EHR Care Plans Triggered Based on Risk Assessment Braden Scale for Predicting Pressure … Sore Risk SENSORY PERCEPTION 1.

105. Addressing Questions Asked by Staff: Wound Cleaning (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-wound-cleaning.pdf
     March 01, 2022 - CHG in 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/

106. 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 … leading 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

107. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
     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 … Ulcers MPSMS (2015) Hospital-Acquired Pressure Ulcers 1,190,000 36.3 Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC. … [7] The AHRQ-developed pressure ulcer toolkit and falls toolkit are online.

108. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
     September 01, 2014 - Obstetric 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 … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated Pneumonia … 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

109. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     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 … Ulcers ( (“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “Bedsore” [tiab] OR “Bed Sores” [tiab … ] OR “Decubitus Ulcer” [tiab] OR “Pressure Sore” [MeSH] OR “Pressure Sore” [tiab] OR “Suspected Deep … Tissue Injury” [tiab] OR “Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ulcer All hospitalized patients who are at risk to have pressure ulcer 0.018c 2.42–5.06 3.26

110. NPSD Dashboards | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/index.html
     October 01, 2023 - Pressure Ulcer Dashboard Details the documentation of increased risk for pressure ulcer following a … risk assessment; and the timing of the first risk assessment for reported pressure ulcers or sDTIs.

111. 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 … leading 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

112. How To Measure Pressure Injury Rates and Prevention Practices
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
     July 02, 2008 - Care plan addressing every deficit on pressure ulcer risk factor assessment has been developed and is … 46 Next Steps Over the next several weeks, we will meet weekly to refine your Action Plan for the Pressure … Ulcer Prevention Program.

113. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - ulcers, and about 16 percent from catheter-associated urinary tract infections (CAUTIs) ( Exhibit 4 … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC. 1 AHRQ Partnership for Patients Web page

114. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/methods.html
     December 01, 2017 - 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 … Tract Infections 18.80 25.58 0.73 Falls In-Hospital Patient Falls 12.25 14.56 0.84 Pressure … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated Pneumonia … Ulcer MPSMS Hospital-Acquired Pressure Ulcers 1,317,211 32,750,000 40.220 Surgical Site

115. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
     July 01, 2020 - ulcers/pressure injuries and falls. … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/ Pressure Injuries 21.7 23.5 22.7 23.0 6% Surgical Site Infections 2.5 2.5 2.5 2.7 8% … Ulcer MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs … Ulcer MPSMS Hospital- Acquired Pressure 647,096 21.75 699,790 23.52 676,834 22.75 682,984 22.96

116. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
     January 01, 2016 - ulcers and falls. … ulcers increased from 2014 to 2016. … Ulcer MPSMS Hospital-Acquired Pressure Ulcers Surgical Site Infection NHSN SSIs for 17 procedures … Ulcer MPSMS Hospital-Acquired Pressure Ulcers 643,230 21.62 Surgical Site Infection NHSN SSIs … Ulcer MPSMS Hospital-Acquired Pressure Ulcers 0643,23 21.62 708,301 23.81 704,906 23.69 Surgical

117. Module 1: Preventing Pressure Injuries in Hospitals (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
     July 12, 2017 - Ulcers in Hospitals Toolkit training. … Preventing in-facility pressure ulcers. … Ulcers in Hospitals Toolkit. … Preventing in-facility pressure ulcers. … Preventing in-facility pressure ulcers.

118. Introduction to the Quality Indicators Best Practices Tool (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
     June 05, 2016 - Best practices forms exist for the following 14 PSIs: • PSI 03 Pressure Ulcer Rate • PSI 05 Retained … 03 Neonatal Blood Stream Infection Rate • PDI 01 Accidental Puncture or Laceration Rate • PDI 02 Pressure … Ulcer Rate • PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count • PDI 05 Iatrogenic

119. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/interimhac2013-ap4.html
     December 01, 2014 - Obstetric Adverse Events 380,000 30% 50% 15% 57,000 $3,000 .0015 $171,000,000 84 Pressure … Ulcers 250,000 50% 50% 25% 62,500 $17,000 .072 $1,062,500,000 4,525 Surgical Site … Ulcers were modified in 2012 from earlier higher projections. … been wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure … ulcer, rather than on the incremental cost due to the HAC.   18.

120. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
     January 01, 2019 - ulcers/pressure injuries and falls. … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/ Pressure Injuries 21.7 23.5 22.7 23.0 6% 17.4 Surgical Site Infections 2.5 2.5 2.5 … Ulcer MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs … Ulcer MPSMS Hospital- Acquired Pressure 647,096 21.75 699,790 23.52 676,834 22.75 682,984 22.96