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221. C1 Prioritization Worksheet (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
     June 02, 2025 - Patient Safety PSI 03 Pressure Ulcer   PSI 06 Iatrogenic Pneumothorax PSI 07 Central Venous Catheter-Related … Neonatal Blood Stream Infection Rate Pediatric PDI 01 Accidental Puncture or Laceration Rate PDI 02 Pressure … Ulcer Rate PDI 05 Iatrogenic Pneumothorax Rate PDI 06 RACHS-1 Pediatric Heart Surgery Mortality

222. Table 9: Outcome Indicators by Selected Home and Community-Based Services Medicaid State Plan Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab9.html
     February 01, 2023 - Overall Yes 18,922 20,115 18,052 19,228 No 28,131 18,583 22,752 19,363 Pressure … Ulcer Yes 3,471 3,655 3,237 3,421 No 3,873 3,358 4,221 4,253 Injurious … Composite: ACSC Overall 19,083 19,110 16,427 19,636 23,560 27,103 21,664 20,810 Pressure … Ulcer 3,504 3,473 2,888 3,575 2,944 4,236 4,000 3,773 Injurious Falls 285

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

224. Table 19F: HCBS Population Ages 18-64 Without I/DD or SMI | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19f.html
     March 01, 2023 - 5,990 6,632 Composite: ACSC Overall 23,094 19,763 20,681 21,282 21,204 19,420 Pressure … Ulcer 6,082 4,303 4,919 4,872 4,765 5,535 Injurious Falls 173 119 141 130 … 5,861 6,673 6,037 6,455 Composite: ACSC Overall 20,343 22,153 21,427 18,076 Pressure … Ulcer 4,499 5,846 4,870 5,072 Injurious Falls 140 131 131 168 Notes

225. Table 19G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19g.html
     March 01, 2023 - 12,136 Composite: ACSC Overall 32,463 23,973 25,306 28,599 25,757 29,466 Pressure … Ulcer 4,845 3,916 4,034 4,473 4,279 3,822 Injurious Falls 694 450 520 525 … 12,380 10,227 12,540 Composite: ACSC Overall 24,470 31,390 25,983 29,126 Pressure … Ulcer 4,169 4,242 4,328 3,449 Injurious Falls 498 580 497 653 Notes

226. Table 19E: SMI Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19e.html
     March 01, 2023 - 6,924 7,208 Composite: ACSC Overall 20,218 17,976 20,084 17,046 19,215 17,075 Pressure … Ulcer 3,124 2,492 3,084 2,232 2,819 2,301 Injurious Falls 297 218 268 212 … 6,471 8,020 7,037 6,881 Composite: ACSC Overall 17,757 20,393 19,476 16,171 Pressure … Ulcer 2,658 2,731 2,846 2,191 Injurious Falls 239 247 236 260 Notes

227. Table 19D: I/DD Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19d.html
     March 01, 2023 - 3,685 2,830 Composite: ACSC Overall 6,401 5,144 6,083 4,903 6,049 4,408 Pressure … Ulcer 1,887 1,225 1,703 1,115 1,573 1,084 Injurious Falls 88 67 77 69 79 … 3,503 3,242 3,720 2,668 Composite: ACSC Overall 5,768 5,111 6,087 4,163 Pressure … Ulcer 1,543 1,223 1,589 999 Injurious Falls 77 67 77 63 Notes:  

228. Table 19C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19c.html
     March 01, 2023 - 4,435 3,912 Composite: ACSC Overall 14,847 12,685 13,750 12,591 14,039 10,413 Pressure … Ulcer 3,144 1,922 2,311 2,203 2,306 2,125 Injurious Falls 114 46 72 55 58 … 4,284 4,429 4,470 3,725 Composite: ACSC Overall 13,151 13,631 14,134 9,746 Pressure … Ulcer 2,071 2,713 2,345 1,945 Injurious Falls 68 59 59 92 Notes:  

229. Table 19B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19b.html
     March 01, 2023 - 8,456 8,118 Composite: ACSC Overall 25,741 19,330 21,845 20,450 21,888 19,402 Pressure … Ulcer 4,659 3,573 4,127 3,570 4,133 3,186 Injurious Falls 476 335 399 346 … 8,162 8,798 8,469 8,012 Composite: ACSC Overall 20,856 22,154 22,042 18,402 Pressure … Ulcer 4,014 3,688 4,171 2,882 Injurious Falls 384 365 381 366 Notes

230. Table 19A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19.html
     March 01, 2023 - 7,387 7,164 Composite: ACSC Overall 23,095 17,584 19,743 18,467 19,802 17,363 Pressure … Ulcer 4,291 3,139 3,655 3,225 3,647 2,945 Injurious Falls 388 259 314 272 … 7,138 7,741 7,427 6,977 Composite: ACSC Overall 18,821 20,092 19,980 16,312 Pressure … Ulcer 3,501 3,452 3,695 2,655 Injurious Falls 301 291 297 299 Notes

231. Table 11: Outcome Indicators by Use of Selected Home and Community-Based Services Medicaid State Plan Services, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab11.html
     February 01, 2023 - Overall Yes 14,177 28,212 18,788 9,372 No 19,380 19,211 19,521 20,716 Pressure … Ulcer Yes 2,730 11,421 3,150 1,840 No 3,506 3,461 3,696 3,731 Injurious … Composite: ACSC Overall 50,783 40,549 9,972 20,001 18,997 10,923 20,108 19,218 Pressure … Ulcer 12,696 8,204 883 4,475 3,415 1,644 3,729 3,459 Injurious Falls 469

232. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - It is more difficult for staff to identify which residents are at risk for a fall or pressure ulcer or … 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 … 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 tested

233. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
     November 19, 2015 - About 40 percent of this 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 … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 7 2010 baseline data … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC. 13 Saving Lives and Saving Money: Hospital-Acquired

234. AHRQ Patient Safety Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/PS-tools-2024.pdf
     January 01, 2024 - Web: ahrq.gov/goinghomeguide/ Pressure Ulcers Preventing Pressure Ulcers: A Toolkit for Improving … Quality of Care in Hospitals assists hospital staff in implementing effective pressure ulcer prevention … Ulcers in Hospitals Toolkit. … Web: ahrq.gov/pressureinjuryprevtraining Safety Program for Nursing Homes: On-Time Pressure Ulcer … ulcers.

235. Data Submission Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2024.xlsx
     January 01, 2024 - 10.5% Surgery or Anesthesia CFER-H V1.1 25,264 9.4% Surgery or Anesthesia CFER-H V1.2 132,724 5.2% Pressure … Ulcer CFER-H V1.1 16,374 6.1% Pressure Ulcer CFER-H V1.2 124,964 4.9% Device or Medical/Surgical Supply

236. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/small_hospitals-slides/Small-and-Rural-Critical-Access-Hospitals-July-19-2011-508.ppt
     January 01, 2011 - Ulcers on the Unit Develop a team -- Include staff nurses Gather baseline data Have first team meeting … ; educate on science of safety, data, goals Research the evidence-based practices that eliminate pressure … ulcers The CUSP/Improvement Intervention Alt text CUSP 1. … Provide feedback, investigate each case Eliminate Stage 3, 4 Pressure Ulcers 1. … Standardized pressure ulcer risk assessment 3.

237. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/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

238. Draft Final Report Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital Acquired Conditions (pdf file)
     www.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

239. FAQs (Staff): Wound Cleaning (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-wound-cleaning.docx
     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/rashes

240. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
     www.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 … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated … 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