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421. 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/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

422. Preventing CAUTI in Specialized Patient Populations: The ICU | Agency for Healthcare Research and Quality
     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

423. Paul Tedrick (doc file)
     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

424. Recovering After Emergency Laparotomy (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/laparotomy-patient.pdf
     November 01, 2023 - Recovering After Emergency Laparotomy Recovering After Emergency Laparotomy e Emergency Laparotomy Patient Education Guide 1 Recovering After Emergency Laparotomy Patient Name ___________________________________________________________________ Surgeon Name ________________________________________________…

425. Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings (pdf file)
     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

426. 2019 National Healthcare Quality and Disparities Report Quality Trends (pdf file)
     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

427. Preventablehospitalandedvisits-Implmatl (pdf file)
     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.

428. Final Progress Report: Effects of Patient Turnover on Nursing Care and Patient Outcomes in Acute Care Hospital Settings (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/park-report.pdf
     January 01, 2024 - NDNQI Unit-acquired pressure injury Unit Number of patients who acquired a pressure ulcer after arrival … to the unit/total number of patients assessed in the pressure ulcer survey.

429. Final Progress Report: A National Report of Nursing Home Quality Measures and Information Technology (pdf file)
     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.

430. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=3
     January 01, 2024 - Grant Number: R01 HS 22903 Topic(s): Pressure Ulcers Publication Date: June 2020 Occult Uterine

431. Preventing Device-Associated Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section4.html
     October 01, 2015 - associated with many infectious and noninfectious complications including immobility (with potential pressure … ulcers and increased risk for thromboembolism), trauma, and debility.

432. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-slides.pptx
     January 01, 2017 - Estimated Additional Costs of Healthcare-Acquired Conditions (HACs) Series 1 VAPs SSIs CLABSI Other HACs Pressure … Ulcers Post-op DVTs Falls Adverse Drug Events Obstetric Adverse Events CAUTI 21001 21000 17000 17000 … Sheet1 Series 1 VAPs $ 21,001 SSIs $ 21,000 CLABSI $ 17,000 Other HACs $ 17,000 Pressure … Ulcers $ 17,000 Post-op DVTs $ 8,000 Falls $ 7,234 Adverse Drug Events $ 5,000 Obstetric

433. Improving the Value of Patient Safety Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
     June 12, 2008 - taxonomies include mistakes (e.g., prescribing errors) and the outcome of mistakes (e.g., p falls, decubitus … ulcers) as event types. … However, falls and decubitus ulcers are visible ha (outcomes) that might have resulted from failure to … the proportion of incidents in the ICUSRS with harm identified, it is not surprising that falls and decubitus … ulcers were among the highest.

434. Appendix E | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
     April 01, 2018 - Delirium 2 427  -- Nosocomial Infections 3 450  -- Patient Falls 11 428  -- Pressure … Ulcers 5 430  -- Venous Thrombosis and Thromboembolism 0 414 Medication Safety

435. Session 2 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html
     October 01, 2014 - Reddened or darkened skin near a pressure point, or skin breakdown in those areas, can lead to a full pressure … ulcer (bed sore) if not responded to promptly.

436. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - have also been instrumental in the development of programs for falls risk assessment and mitigation, pressure … ulcer risk assessment and mitigation, and a suicide risk assessment, all of which have been hard-wired … assessments, implemented in 14 organizations, require every nurse to assess each patient’s risk for falls, pressure … ulcers, and suicide consistently across all 14 organizations. … There has been a 36 percent reduction in the pressure ulcer rate since July 2006.

437. Prevehosp-Reports-Ig (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-reports-ig.pdf
     November 30, 2013 - ulcer  Peripheral vascular disease  Respiratory, other nonpneumonia  Renal disease  Seizure … 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. … ulcer. … If there is a pressure ulcer stage 2, 3, 4, or unstageable recorded as present within 7 days of the

438. Supportive and Palliative Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/supportive.html
     June 01, 2018 - Weight loss also may lead to muscle wasting, infections, and increased risk of pressure ulcers.

439. Adaptation of AHRQ Patient Safety Indicators for Use in ICD-10 Administrative Data by an International Consortium (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Quan_52.pdf
     March 10, 2008 - puerperium) No No PSI 2: Death in low- mortality No, because it heavily relies on DRG PSI 3: Decubitus … ulcer Yes All medical and surgical discharges age ≥18 years, length of stay >4 days MDC 9 (skin … For decubitus ulcer (PSI 3), a major exclusion group covers hemiplegias and other neurologic problems … Although there are specific codes for decubitus ulcer (PSI 3) in both ICD-9-CM and ICD-10-WHO, the ICD … -10-WHO code L89 (decubitus ulcer) does not specify the site of the ulcer, while M70 codes describe

440. Hospital Expands Use of AHRQ’s QI Toolkit To Improve Patient Safety Measures Prioritized by Medicare (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/standalone_psi_casestudy.pdf
     June 02, 2025 - five PSIs that have been identified as priorities at HMC based on the volume of cases: • PSI 03 Pressure … Ulcer Rate • PSI 07 Central Venous Catheter-Related Blood Stream Infection Rate • PSI 11 Postoperative