-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Clair.pdf
January 01, 2004 - The WRAMC Department of Nursing is presently developing
similar evidence-based procedures for pressure … ulcer prevention, deep vein
thrombosis prophylaxis, and for enteral feeding. … Ongoing and future projects funded
through the TriService Nursing Research Program (TSNRP) include pressure … ulcer prevention, deep vein thrombosis prophylaxis, and enteral feeding
precautions to reduce aspiration
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www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/pediatric.html
December 01, 2017 - Introduction PDF [ - 38.47 KB]
PDI01 Accidental Puncture or Laceration PDF [ - 62.74 KB]
PDI02 Pressure … Ulcer PDF [ - 110.08 KB]
PDI03 Foreign Body PDF [ -96.96 KB]
PDI05/NQI01 Iatrogenic Pneumothorax
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives-notes.docx
April 01, 2022 - They are as follows:
· Stage III or stage IV or unstageable pressure ulcers
· Moderate to severe incontinence-associated … urinary retention with or without bladder outlet obstruction
· Stage III or stage IV or unstageable pressure … ulcer, or similarly severe wounds of other types, that cannot be kept clear of urinary incontinence
-
www.ahrq.gov/news/newsroom/case-studies/201419.html
November 01, 2014 - other patient safety issues such as falls prevention, medication safety, urinary tract infection, and pressure … ulcers.
-
www.ahrq.gov/hai/pfp/haccost2017-discuss.html
November 01, 2017 - 0.035–0.070)
0.055
OBAE
$602 (-$578–$1,782)
$3,271
0.005 (0.003–0.013)
0.0015
Pressure … Ulcers
$14,506 (-$12,313–$41,326)
$18,537
0.041 (0.013–0.093)
0.072
SSI
$28,219 ($18,237 … In all other HACs, while we observed some increase (CAUTI) and some decrease (ADE, pressure ulcers) compared
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
March 01, 2013 - “common;” examples include falls,
venous thromboembolism (VTE), potential adverse drug
events, or pressure … ulcers. … ulcers;
and PSPs designed to improve the overall system or to
address multiple patient safety targets … ulcers; in-depth review
Common/
Moderate
Moderate Negligible Moderate Moderate/
Moderate
9
Table … ulcers, and other
nursing sensitive outcomes (other than
mortality); in-depth review
Common/High
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
November 30, 2013 - • Current clinical conditions contributing to transfer risk: use of oxygen, catheter or
ostomy, any pressure … ulcer other than stage I, fall risk, late-loss activities of daily living
(ADL) score greater than or … ulcer.
• Fall risk or previous fall in last 90 days.
• Late-loss ADL score ≥12.
• Cognitive impairment … active medications during the
report week, active high-risk diagnosis of UTI, presence of Stage III pressure … ulcer, and two medical conditions, cellulitis and hypertension, would trigger
Rule 2.
3.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
September 01, 2017 - ulcer, fall risk, late-loss ADL index score greater than or equal to 12 [based on RUG-III], cognitive … ulcer, fall risk, late-loss ADL index score greater than or equal to 12 [based on RUG-III], cognitive … ulcer, and two medical conditions (cellulitis and hypertension) would trigger Rule 2. … Presence of stage 2 or greater pressure ulcer. … If there is a pressure ulcer stage 2, 3, 4, or unstageable recorded as present within 7 days of the report
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www.ahrq.gov/funding/training-grants/disgrants.html
October 01, 2014 - University of Illinois at Chicago
Using an Electronic Health Record to Examine Nurse Continuity and Pressure … Ulcers
8/31/2015
Van Parys, Jessica
R36 HS23504-01
Columbia University Health Sciences
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
January 01, 2010 - Smith (2)
Because of his immobility, he develops a pressure ulcer on his sacrum. … would protect the skin in the incontinent patient, and a catheter may prove useful in advanced stage pressure … ulcers, but to protect intact skin, there are many other products that can create a barrier.
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part3-nqs2.html
October 01, 2015 - restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-trache.pdf
June 02, 2025 - NICU Family Information Packet, Appendix B, Tracheostomies
Tracheostomies
Tracheostomy Basics
■ Indications: upper airway obstruction, long term ventilation, ease of pulmonary toilet, to
protect the airway.
■ Tube selection based on:
– Indication for tracheostomy.
– Tracheal width/length/shape.
– Upper a…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-transcript.doc
May 13, 2014 - they were also that because of her immobility and functional incontinence that she might develop a pressure … ulcer or skin breakdown. … She started to get decubitus ulcers from her immobility, very stage I stage II decubitus ulcers. … And then she gets the CAUTI, which results in C. diff, which results in a pressure ulcer, increased length
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www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-specialized-populations-icu.html
December 01, 2017 - they were also that because of her immobility and functional incontinence that she might develop a pressure … ulcer or skin breakdown. … She started to get decubitus ulcers from her immobility, very stage I stage II decubitus ulcers. … And then she gets the CAUTI, which results in C. diff , which results in a pressure ulcer, increased
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-slides.html
September 01, 2017 - showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure … ulcer, and two medical conditions: cellulitis and hypertension. … DNR,DNH, MOLST, or POLST Order in Place
Oxygen Therapy
Catheter or Ostomy Present
Stage II or > Pressure … Ulcer
Fall Risk
Late-Loss ADL Score ≥12
Cognitive Impairment
Medical Conditions **
High-Risk
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www.ahrq.gov/news/newsroom/case-studies/201411.html
August 01, 2014 - Mercy also replaced patient beds to reduce incidents of pressure ulcers and to promote patient and staff
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Savitz.pdf
March 01, 2004 - overarching indicators related to medication
administration errors, nosocomial infections, patient falls, pressure … ulcers, and
mortality, with increasing detail in measure specification.11 For example,
nosocomial … accepted
n=7)
Provisional NQF
(n=13)
ANA
(n=10)
Death in low mortality DRG X
Decubitus/pressure … ulcer X X X
Failure to rescue X X X
Infection due to medical care X
• Urinary tract infection … We see virtually no direct overlap in these
measure sets, with the exception of decubitus/pressure ulcer
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
January 01, 2019 - nursing home residents with a
urinary tract infection (MDS)
4.9% in 2013 2.2% in 2017 -18.2 0.003
Pressure … Ulcers Short-stay nursing home patients with new or
worsening pressure ulcers (MDS)
0.7% in 2013 … residents with
a catheter inserted and left in the bladder
(MDS)
3.4% in 2013 2.8% in 2017 -5.4 0.008
Pressure … Ulcers High-risk, long-stay nursing home patients with
pressure ulcer (MDS)
5.3% in 2013 4.8% in
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www.ahrq.gov/sites/default/files/2024-07/alexander-report.pdf
January 01, 2024 - sores; 4) who are at low risk and who
have pressure sores; 5) who are physically restrained; 6) who … sores. … Ulcers 13938 787 5.9 5.6
Who Lose Too Much Weight 14183 798 7.4 7.5
Bowel or Bladder Incontinent 13038 … Ulcers -0.01 -0.05 0.01 0.05 0.02 0.04 0.05 0.02 -0.01 0.01
Who Lose Too Much Weight 0.05 0.05 0.05 … Ulcers, and % Short Stay
Assessed/Given Pneumococcal Vaccine.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/preventablehospitalandedvisits-implmatl.pdf
June 03, 2025 - status
Oxygen dependency
Confusion/mental status change
Any full thickness wound (e.g., pressure … ulcers [Stage II or greater], surgical
wound, stasis ulcer)
Polypharmacy (15 or more medications … Chronic pressure ulcers Yes No
L. Recurrent UTI Yes No
M. Anemia Yes No
N.