- 
                                        
www.ahrq.gov/sites/default/files/2024-04/baernholdt-report.pdf
January 01, 2024 - Key Words: Pressure ulcers, falls, National Database of Nursing Quality Indicators, 
nurse outcomes, … SCOPE
Pressure ulcers and falls are among the most common, preventable, and costly patient 
safety events … Patients at risk for 
pressure ulcer 
Percentage of patients with pressure 
ulcers who received this … a 
hospital acquired pressure ulcer
Unit-acquired 
pressure ulcer 
rate
Prevalence rate collected … We find that unit-level care interventions do make a difference in 
preventing pressure ulcers.
                                     
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides5.html
October 01, 2017 - Source:  National Pressure Ulcer Advisory Panel. … Source:  National Pressure Ulcer Advisory Panel. … Source:  National Pressure Ulcer Advisory Panel. … Source:  National Pressure Ulcer Advisory Panel. … Source:  National Pressure Ulcer Advisory Panel.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docx
June 02, 2025 - ulcers, pressure ulcers that are not healing appropriately, falls, and avoidable hospitalizations. . … In the packet are the following On-Time Pressure Ulcer Healing documents:
Existing Pressure Ulcers Report … Pressure Ulcers at Risk for Delayed Healing
Weekly Wound Rounds Report
Weekly Pressure Ulcer Treatment … Summary Report
Pressure Ulcer Counts by Month Report 
Pressure Ulcer Healing Self-Assessment
Menu of … MATERIALS:
Existing Pressure Ulcers Report
Pressure Ulcers at Risk for Delayed Healing Report
Weekly
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides3.html
October 01, 2017 - ulcers." … Slide 12: ID Pocket Pad 
 
 Images: The Pressure Ulcer Identification Pocket Pad is shown. … K 
 
 Image: A screenshot shows a sample Braden Pressure Ulcer Risk Assessment scale filled out for Mr … Sore Risk 
 
 
 
 SENSORY PERCEPTION 
 1. … A screenshot shows the Pressure Ulcer Prevention Program Action Plan: June 2015-January 2016.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/slides.html
December 01, 2014 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Facilitator Training … Slide 1: Overview of On-Time 
 
 AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention … Facilitator Training 
 Overview of On-Time 
 Slide 2: On-Time Pressure Ulcer Prevention Facilitator … Pressure Ulcer Healing. 
 Falls Prevention. 
 Prevention of Avoidable Hospitalizations. … Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 4. … (continued) 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in … How do we measure our pressure ulcer rates and practices? 
 6. … ulcers is inevitable. … Hospitals will lose reimbursement for hospital-acquired pressure ulcers.
                                     
                                                                    - 
                                        
www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu4a.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 4. … (continued) 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in … How do we measure our pressure ulcer rates and practices? 
 6. … ulcers is inevitable. … Hospitals will lose reimbursement for hospital-acquired pressure ulcers.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/7.html
December 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Functional Specifications … Specifications for Each Pressure Ulcer Prevention Report (continued) 
 3.7. … Week Ending 
 
 
 4/6/14 
 4/13/14 
 4/20/14 
 4/27/14 
 
 
 
 
 Vital Signs 
 Number of pressure ulcers … Report Column 
 Data Source 
 Valid Input & Display 
 
 
 
 
 Vital Signs 
 
 
 Number of pressure ulcers … Wound Assessment 
 Count number of unique pressure ulcers and display count.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2024.xlsx
January 01, 2024 - of first pressure ulcer risk assessment. … Timing of First Pressure Ulcer Risk Assessment by Most Advanced Stage of Pressure Ulcer or sDTI Reported … Ulcer
	Increased Risk of Pressure Ulcer	Percentage	Frequency
	At increased risk for pressure ulcer	72.6% … PRU_2
	PRU_2: Documented Timing of First Pressure Ulcer Risk Assessment by Most Advanced Stage of Pressure … Ulcer or sDTI Reported
	Timing of first pressure ulcer risk assessment	Most advanced stage of pressure
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apd.html
October 01, 2017 - Ulcer Policies 
			2E: Assessing Screening for Pressure Ulcer Risk 
			2F: Assessing Pressure Ulcer … Ask them to include an example of how to score using their risk assessment scale. 
 3A: Pressure Ulcer … Ulcer Identification Pocket Pad 
			3D: The Braden Scale for Predicting Pressure Sore Risk 
			Mr. … Ulcer Knowledge Test  and staff training needs. … Instructor—facilitated group discussion 
 Education plan for pressure ulcer prevention staff education
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impsteps.docx
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing
Implementation Steps and Timeline … Step 1: Agree To Use On-Time Pressure Ulcer Healing 
Nursing home leadership agrees to incorporate the … Ulcer Assessment and Pressure Ulcer Healing reports are in the system. … ulcers, pressure ulcer healing practices, and communication processes. … Pressure Ulcer Counts by Month Report that identifies pressure ulcer healing rates to provide feedback
                                     
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Successfully negotiating the change process at your hospital.
12
12
Preventing Pressure Ulcers in … Source: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit
19
19
Sustaining Change
Sustain: Changes … The Toolkit’s content draws on literature on best practices in pressure ulcer prevention and includes … CRITICAL SUCCESS FACTORS
GOAL: Decrease the overall rate of hospital-acquired pressure ulcers Stage … Preventing in-facility pressure ulcers.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apc.html
October 01, 2017 - Staff Roles and Training for Your Pressure Ulcer Prevention Program 
 
 Presented by Elizabeth Ayello … Using Pressure Ulcer Risk Assessment Tools in Care Planning 
 
 Presented by Elizabeth Ayello, Ph.D., … Measuring Pressure Ulcer Rates and Prevention Practices 
 
 Presented by Karen Zulkowski, D.N.S., RN. … Risk Factors for Pressure Ulcers: Going Beyond Validated Instruments 
 
 Presented by Elizabeth Ayello … The Power of Nutrition for Pressure Ulcer Prevention 
 
 Presented by Mary D.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overview.html
November 01, 2017 - ulcers, pressure ulcers that are not healing appropriately, avoidable hospitalizations, and falls—and … Evaluation studies of the On-Time pressure ulcers program have shown reductions in pressure ulcers of … Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse … Evaluation of AHRQ's On-Time pressure ulcer prevention program: a facilitator-assisted clinical decision … On-Time Topics 
 
 Pressure Ulcer Prevention . 
 Pressure Ulcer Healing .
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/case.html
December 01, 2017 - Ulcer Prevention Program. … Drop in Pressure Ulcers with AHRQ-Funded Program 
 St. … ulcer development. … ulcer development. … ulcer outcomes.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/pu_training-impguide.docx
October 01, 2017 - Ulcer Risk Assessment Tools in Care Planning
	Risk Factors for Pressure Ulcers: Going Beyond Validated … Ulcer Policies, Tool 2D
Assessing Screening for Pressure Ulcer Risk, Tool 2E
Assessing Pressure Ulcer … Risk Factors for Pressure Ulcers: Going Beyond Validated Instruments 
Presented by Elizabeth Ayello, … Ulcer Policies
2E: Assessing Screening for Pressure Ulcer Risk
2F: Assessing Pressure Ulcer Care Planning … Identification Pocket Pad
3D: The Braden Scale for Predicting Pressure Sore Risk
Mr.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/8.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Functional Specifications … Specifications for Each Pressure Ulcer Prevention Report (continued) 
 3.8. … Return to Functional Specifications Contents   
 Return to Pressure Ulcer Prevention 
 
 
 
 
 
 
 Alternate
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar4_pu_skinassesst_final.pdf
April 01, 2011 - • Provide data needed to calculate pressure 
ulcer incidence and prevalence.
• Stratify risk. … – Patients with existing pressure ulcers are at risk 
for more. … For each patient, record—
• Whether he/she has pressure ulcers
• How many pressure ulcers he/she has … Preventing pressure ulcers in hospitals: a 
toolkit for improving quality of care. … – Tool 3A: Pressure Ulcer Prevention Pathway for Acute Care
– Tool 3C: Pressure Ulcer Identification
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
January 01, 2024 - Ulcer	Communication	167	2.2%
	Pressure Ulcer	Data	*	*
	Pressure Ulcer	Environment	29	0.4%
	Pressure … 0.3%
	Pressure Ulcer	Staff qualifications	184	2.4%
	Pressure Ulcer	Supervisor/Support	*	*
	Pressure … Ulcer	Under 18	Female	No Harm	175	11.8%
	Pressure Ulcer	Under 18	Female	Severe Harm	*	*
	Pressure Ulcer … *	*
	Pressure Ulcer	UNK	Female	Unknown Harm	*	*
	Pressure Ulcer	UNK	Male	Mild Harm	63	75.0%
	Pressure … Ulcer	UNK	Male	Moderate Harm	*	*
	Pressure Ulcer	UNK	Male	No Harm	17	20.2%
	Pressure Ulcer	UNK	Male
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/2.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Functional Specifications … Specifications for Each Pressure Ulcer Prevention Report (continued) 
 3.2. … Return to Functional Specifications Contents   
 Proceed to Next Section 
 Return to Pressure Ulcer Prevention