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41. Documentation and Coding for Patient Safety Indicators (pdf file)
    www.qualitymeasures.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

42. C1 Prioritization Worksheet (xls file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    July 01, 2016 - 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

43. Hospital Resources | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/resource/about.html
    December 01, 2017 - Hospitals Training Program to support the training of hospital staff on how to implement AHRQ’s Preventing Pressure … Ulcers in Hospitals Toolkit . … Preventing Pressure Ulcers in Hospitals Each year, more than 2.5 million people in the United States … develop pressure ulcers. … The aim of this toolkit is to assist hospital staff in implementing effective pressure ulcer prevention

44. Challenge Competition on the Impact of AHRQ’s Patient Safety Tools | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/challenges/patient-safety-tools/index.html
    February 01, 2024 - Ulcers in Hospitals: A Toolkit for Improving Quality of Care to decrease Patient Safety Indicator 03 … 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. … 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.

45. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
    www.qualitymeasures.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.

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

47. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/index.html
    March 01, 2024 - Ulcers in Hospitals Re-Engineered Discharge Toolkit QI Toolkit Venous Thromboembolism … 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.

48. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/hai/pfp/2015-interim.html
    December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … Ulcers MPSMS (2015) Hospital-Acquired Pressure Ulcers 1,190,000 36.3 Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC. … [7] The AHRQ-developed pressure ulcer toolkit and falls toolkit are online.

49. NPSD Dashboards | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/npsd/data/dashboard/index.html
    October 01, 2023 - Pressure Ulcer Dashboard Details the documentation of increased risk for pressure ulcer following a … risk assessment; and the timing of the first risk assessment for reported pressure ulcers or sDTIs.

50. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/hai/pfp/2014-final.html
    January 01, 2018 - 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. 1 AHRQ Partnership for Patients Web page

51. Methods To Estimate the Baseline 2010 PFP National Hospital-Acquired Condition Rate | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/hai/pfp/methods.html
    December 01, 2017 - 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 … Tract Infections 18.80 25.58 0.73 Falls In-Hospital Patient Falls 12.25 14.56 0.84 Pressure … Ulcers Hospital-Acquired Pressure Ulcers 53.03 62.45 0.85 VAP Ventilator-Associated Pneumonia … Ulcer MPSMS Hospital-Acquired Pressure Ulcers 1,317,211 32,750,000 40.220 Surgical Site

52. AHRQ National Scorecard on Hospital-Acquired Conditions: Final Results for 2014 Through 2017 (pdf file)
    www.qualitymeasures.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

53. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2016 (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
    January 01, 2016 - ulcers and falls. … ulcers increased from 2014 to 2016. … Ulcer MPSMS Hospital-Acquired Pressure Ulcers Surgical Site Infection NHSN SSIs for 17 procedures … Ulcer MPSMS Hospital-Acquired Pressure Ulcers 643,230 21.62 Surgical Site Infection NHSN SSIs … Ulcer MPSMS Hospital-Acquired Pressure Ulcers 0643,23 21.62 708,301 23.81 704,906 23.69 Surgical

54. Introduction to the Quality Indicators Best Practices Tool (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
    June 05, 2016 - 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

55. AHRQ Pediatric Quality Indicators Prioritization Worksheet (pdf file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.pdf
    June 05, 2016 - 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

56. Table 17D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17d.html
    February 01, 2023 - 3,252 3,815 3,120 Composite: ACSC Overall 6,079 4,558 5,662 5,312 6,245 5,000 Pressure … Ulcer 1,619 1,071 1,367 1,440 1,749 1,185 Injurious Falls 81 60 90 55 92 60 … Conditions 3,481 3,208 3,831 3,228 Composite: ACSC Overall 5,719 5,011 6,399 5,136 Pressure … Ulcer 1,498 1,217 1,890 1,213 Injurious Falls 80 57 88 68 Notes:   ACSC =

57. Table 17A: National HCBS Population | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17.html
    February 01, 2023 - 6,749 9,215 6,184 Composite: ACSC Overall 22,374 14,832 21,534 17,751 23,720 16,492 Pressure … Ulcer 4,168 2,525 3,903 3,214 4,382 2,935 Injurious Falls 316 271 324 280 375 … Conditions 7,298 7,429 9,114 6,570 Composite: ACSC Overall 19,447 18,724 23,221 17,538 Pressure … Ulcer 3,603 3,194 4,378 3,086 Injurious Falls 301 289 382 264 Notes:   ACSC

58. Table 17B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
    www.qualitymeasures.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 397 350 396 366 462 … Conditions 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:   ACSC

59. Table 17E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17e.html
    February 01, 2023 - 6,781 8,838 5,914 Composite: ACSC Overall 20,734 15,368 19,563 17,756 23,009 16,087 Pressure … Ulcer 2,980 2,213 2,877 2,492 3,415 2,252 Injurious Falls 253 224 263 220 323 … Conditions 6,956 7,098 7,925 6,580 Composite: ACSC Overall 19,175 17,427 20,509 17,826 Pressure … Ulcer 2,820 2,361 3,195 2,436 Injurious Falls 251 221 300 217 Notes:   ACSC

60. Table 17G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
    www.qualitymeasures.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 568 461 588 484 677 … 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:   ACSC