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401. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - ulcer (bed sores); or postoperative sepsis (blood infection). … Decubitus ulcer 5. Failure to rescue 6. Foreign body left during procedure 7. … • Monitoring errors, such as bedsores, failure to rescue, and patient falls. … ulcer monitoring error • Increased checking of inpatients for decubitus ulcers • Monitoring … forms or behavioral checklists • Decubitus ulcer incidence rate feedback • Supervisor praise

402. The Emergency Department & Catheter Insertions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
     December 01, 2017 - Smith (2) Because of his immobility, he develops a pressure ulcer on his sacrum. … Urinary Catheter Harm is in the middle, with several issues surrounding it (i.e. immobility, CAUTI, pressure … ulcers), that could lead to Falls and VTE.

403. Fact Sheet on Patient Safety Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
     October 01, 2015 - Year PSI 02 Death Rate in Low-Mortality Diagnosis- Related Groups (DRGs) 0.32 0347 2012 PSI 03 Pressure … Ulcer Rate 0.50 PSI 04 Death Rate Among Surgical Inpatients with Serious Treatable Complications

404. Many Pediatric Pneumonia Patients Receive Antibiotics Outside of Guidelines | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/967.html
     July 01, 2025 - The latter two areas are primarily concerned with PSIs for pressure ulcers and falls, while the bulk

405. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
     January 01, 2022 - example, maternal-related AE can only be evaluated in a subset of all the sampled claims, while fall and pressure … ulcer can be evaluated from all claims.

406. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
     January 01, 2022 - example, maternal-related AE can only be evaluated in a subset of all the sampled claims, while fall and pressure … ulcer can be evaluated from all claims.

407. A New Model of Tracheostomy Care: Closing the Research–Practice Gap (pdf file)
     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

408. Appendix B7: Wheelchair Seating Assessment (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manwsa.html
     December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix B7: Wheelchair Seating Assessment (Text Description) Previous Page Next Page Table of Contents The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 1. Introductio…

409. Pediatric Toolkit for Using the AHRQ Quality Indicators | Agency for Healthcare Research and Quality
     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

410. Central Venous Catheter Indications and Alternatives Facilitator Notes (doc file)
     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

411. Peterson Regional Medical Center Uses AHRQ's CUSP and Hospital Survey to Advance Patient Safety | Agency for Healthcare Research and Quality
     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.  

412. Discussion | Agency for Healthcare Research and Quality
     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

413. Making Health Care Safer II, Executive Summary (pdf file)
     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

414. On-Time Preventable Hospital and Emergency Department Visits (pdf file)
     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.

415. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     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

416. ChartBook On Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pdf
     March 04, 2016 -  Among the most frequent HACs, between 2010 and 2014, the rate of pressure ulcers decreased the …  Nursing home residents who have pressure ulcers. … Pressure Ulcers Low-risk short-stay and high-risk long-stay nursing home residents who have pressure …  Overall Percentage: In 2013, the percentage of low-risk short-stay residents with pressure ulcers … was 1.3% and the percentage of high-risk long-stay residents with pressure ulcers was 7.7%

417. Recently Funded Dissertation Grants | Agency for Healthcare Research and Quality
     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

418. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
     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.

419. National Quality Strategy Priorities: Patient Safety | Agency for Healthcare Research and Quality
     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.

420. NICU Family Information Packet, Appendix B, Tracheostomies (pdf file)
     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…