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www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals/slides.html
October 01, 2014 - Walking Through the Process
Eliminate Hospital-Acquired Stage 3/4 Pressure Ulcers on the Unit … meeting; educate on science of safety, data, goals
Research the evidence-based practices that eliminate pressure … ulcers
Return to Contents
Slide 13. … unit
Implement teamwork tools
Provide feedback, investigate each case
Eliminate Stage 3, 4 Pressure … Ulcers
Comprehensive skin assessment
Standardized pressure ulcer risk assessment
Care planning
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pptx
October 01, 2015 - Ulcer Rate
PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count
PDI 05 Iatrogenic Pneumothorax … ulcer)
Denominator = population at risk (e.g., hospitalized patients)
Observed rate = numerator/denominator … 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)
Tool A.2 Slide ‹#›
Pediatric Toolkit for Using the AHRQ Quality
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www.ahrq.gov/topics/injuries-and-wounds.html
Topic: Injuries and Wounds
AHRQ wound research centers on pressure ulcers.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find4.html
December 01, 2012 - All but two of the indicators (Pressure Ulcer and Injurious Falls) build on existing AHRQ Prevention … Pressure Ulcer.
Injurious Falls.
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www.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
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www.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/
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
June 02, 2025 - 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.
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www.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.
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www.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
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
September 01, 2017 - Slide 6: On-Time Reports for Four Adverse Events
Four Reports:
Pressure Ulcer Prevention. … Pressure Ulcer Healing.
Falls Prevention.
Preventable Hospital and ED Visits. … Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
October 01, 2017 - Slide 6: On-Time Reports for Four Adverse Events
Four Reports
Pressure Ulcer Prevention
Pressure … Ulcer Healing
Falls Prevention
Preventable Hospital and ED Visits
Slide 7: Common Elements … Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation.
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www.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
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www.ahrq.gov/es/tools/index.html?page=3
June 01, 2016 - Date Published: August 2016
Setting of Care: Hospital
Preventing Pressure Ulcers … in Hospitals
These materials assist hospital staff in implementing effective pressure ulcer prevention
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www.ahrq.gov/hai/pfp/hacrate2011-12.html
January 01, 2018 - Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
82,000
2.51
77,000
2.36
Pressure … Ulcer
MPSMS
Hospital-Acquired Pressure Ulcers
1,320,000
40.41
1,300,000
39.43
Surgical
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www.ahrq.gov/patient-safety/reports/engage/appc.html
March 01, 2017 - ab] OR prevention [ab] OR reducing [ab] OR reduction [ab] OR aged [mh] OR elderly OR geriatric)) OR Decubitus … Ulcer [mh] OR ((pressure [ti] OR decubitus [ti]) AND ulcer* [ti]) OR decubiti [ti])) AND ((((Randomised
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 02, 2025 - 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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
March 15, 2016 - ulcers). … ulcers or CLABSI, deaths, oncology patients). … PDI 02 Pressure Ulcer Rate (stage
III, IV, Unstageable)
Diagnosis and site of pressure ulcer must … PDI 02 Pressure Ulcer X If the ulcer progresses from one stage
to another higher stage during the
encounter … Provider must document the site of
pressure ulcer; the stage of the ulcer
can be documented and coded
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www.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
-
www.ahrq.gov/hai/pfp/haccost2017.html
November 01, 2017 - Pressure Ulcers.
Surgical Site Infections.
Venous Thromboembolism. … Ulcers
Surgical Site Infections
Ventilator Associated Pneumonia
Venous … Ulcers
Surgical Site Infections (SSI)
Venous Thromboembolism (VTE)
Ventilator-Associated Pneumonia … Pressure Ulcers
A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s) present … ulcer.
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www.ahrq.gov/hai/pfp/haccost2017-results.html
November 01, 2017 - Pressure Ulcers
Based on three studies reporting cost data, we estimated the additional cost for hospital-acquired … pressure ulcers to be $14,506 (95% CI: -$12,313 to $41,326), whereas excess mortality, based on three … ulcer cases, there are 41 excess deaths). … ulcers. … (Goudie 2015) and estimated the additional cost for hospital-acquired pressure ulcers among adult inpatients