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221. Table 17G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17g.html
     February 01, 2023 - 13,941 8,615 Composite: ACSC Overall 31,820 19,437 32,312 23,141 34,235 21,902 Pressure … Ulcer 5,156 2,917 5,215 3,604 5,195 3,597 Injurious Falls 568 461 588 484 … 10,221 11,658 13,626 9,337 Composite: ACSC Overall 25,759 28,549 32,778 23,897 Pressure … Ulcer 4,379 3,646 4,962 3,857 Injurious Falls 504 573 687 457 Notes

222. Table 17B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17b.html
     February 01, 2023 - 10,530 7,005 Composite: ACSC Overall 24,760 16,334 23,622 19,729 26,330 18,086 Pressure … Ulcer 4,583 2,937 4,303 3,638 4,774 3,353 Injurious Falls 397 350 396 366 … 8,314 8,522 10,408 7,479 Composite: ACSC Overall 21,408 21,005 25,803 19,316 Pressure … Ulcer 4,098 3,440 4,727 3,530 Injurious Falls 384 363 466 342 Notes

223. Table 10: Outcome Indicators by Selected Home and Community-Based Services 1915(c) Waiver Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab10.html
     February 01, 2023 - Composite: ACSC Overall Yes 22,422 20,395 25,160 No 18,138 19,018 17,666 Pressure … Ulcer Yes 5,006 4,208 4,833 No 2,960 3,348 3,127 Injurious Falls Yes 307 … 7,607 Composite: ACSC Overall 20,384 19,444 14,877 19,094 19,184 20,443 Pressure … Ulcer 4,195 4,249 2,476 3,395 3,286 3,764 Injurious Falls 388 259 218

224. Documentation and Coding for Patient Safety Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
     March 15, 2016 - ulcers). … PDI 02 Pressure Ulcer Rate (stage III, IV, Unstageable) Diagnosis and site of pressure ulcer must … PSI 03 Pressure Ulcer Encourage providers to document pressure ulcers as part of the admission H&P to … Provider must document the site of pressure ulcer; the stage of the ulcer can be documented and coded … PSI 03 Pressure Ulcer X “Unspecified stage” and “unstageable” are not interchangeable terms; the code

225. Board and Senior Leadership PowerPoint Presentations on the Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
     October 01, 2015 - ulcer) • Denominator = population at risk (e.g., hospitalized patients) • Observed rate = numerator … ulcer in any secondary diagnosis field among cases meeting the inclusion and exclusion rules for the … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02) http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)� How can the AHRQ PDIs be used in�quality assessment?

226. Improving Patient Safety in Nursing Homes: A Resource List (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-resource-list-2.0.pdf
     April 01, 2025 - Pressure Ulcer Reduction 1. … Braden Scale for Predicting Pressure Sore Risk https://www.in.gov/health/files/Braden_Scale.pdf This … ulcers. … Use this tool to identify a) residents admitted the current month with pressure ulcers and b) others … who developed a pressure ulcer within the month. 4.

227. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
     December 01, 2016 - 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.

228. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
     December 01, 2016 - 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.

229. Table 12: Outcome Indicators by Use of Selected Home and Community-Based Services 1915(c) Waiver Services, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab12.html
     February 01, 2023 - Composite: ACSC Overall Yes 26,515 17,685 7,028 No 18,855 19,300 20,127 Pressure … Ulcer Yes 6,274 3,455 1,049 No 3,338 3,486 3,662 Injurious Falls Yes 369 … 7,404 Composite: ACSC Overall 6,233 33,102 8,819 20,714 16,992 19,479 Pressure … Ulcer 1,013 6,793 2,359 3,765 2,949 3,511 Injurious Falls 157 543 138

230. 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

231. 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
     October 01, 2015 - The estimated cost per pressure ulcer was based on a report for CMS by RTI international (Kandilov, … Zhan and Miller estimated that excess mortality due to pressure ulcers was 72 deaths per 1,000 pressure … Mortality for patients with pressure ulcer was compared to mortality among a matched set of patients … For example, pressure ulcers had a high baseline prevalence, and excess mortality attributed to pressure … Ulcers MPSMS (2013) Hospital-Acquired Pressure Ulcers 1,060,000 32.5 Surgical Site Infections

232. 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

233. 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

234. 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

235. 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/publications/files/interimhacrate2014_2.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

236. 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

237. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/index.html
     February 01, 2025 - 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.

238. AHRQ's Quality & Patient Safety Programs by Setting: Long-Term Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/index.html
     September 01, 2021 - Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to … help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.

239. 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.

240. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
     www.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