- 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar6_pu_woundassesst.pdf
April 01, 2011 - Ulcers
• 9.1% of all identified 
pressure ulcers
• 11.9% of facility-
acquired pressure 
ulcers
Most … frequent locations
25
Anatomic Location
Percentage of 
Device-Related 
Pressure Ulcers
Ears 20% … Preventing 
pressure ulcers in hospitals: a toolkit for improving 
quality of care. … Ulcers From Other Sources of Pressure
	2009 Pressure Ulcer Definition
	Pressure
	Shear
	Pressure Ulcer … Ulcers
	Remember the Bariatric Patient
	Assess the Wound
	Pressure Ulcer Present
	Know Your Assessment
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
February 10, 2014 - Report Example: Existing Pressure Ulcers Report
	On-Time Existing Pressure Ulcers Report
Unit: A
Date … Residents With New Pressure Ulcers
	Number of current residents with a pressure ulcer that developed … ulcers that have worsened in stage
	All current pressure ulcers
	Pressure Ulcers That Have Increased … Pressure Ulcers That Have Increased in Stage (POA)
	Current POA pressure ulcers that have worsened … Ulcers
	
	All Pressure Ulcers
Unit total number of pressure ulcers by ulcer stage.
                                     
                                                                    - 
                                        
www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 1. Are we ready for this change? … Cost:  Pressure ulcers cost $9.1-$11.6 billion per year in the US. … Pain:  Pressure ulcers may be associated with severe pain. … about pressure ulcer reduction. … Now incidence of pressure ulcers is down to 2 percent.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu1.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 1. Are we ready for this change? … Cost:  Pressure ulcers cost $9.1-$11.6 billion per year in the US. … Pain:  Pressure ulcers may be associated with severe pain. … about pressure ulcer reduction. … Now incidence of pressure ulcers is down to 2 percent.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/comprehensive-program-reduce-rates-hospital-acquired-pressure-ulcers-system-community
May 12, 2021 - Study 
 
 
 
 
 
 
 
 
 
 A comprehensive program to reduce rates of hospital-acquired pressure ulcers … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … This implementation study sought to reduce incidence of  pressure ulcers  in hospitalized patients using … A Comprehensive Program to Reduce Rates of Hospital-Acquired Pressure Ulcers in a System of Community … April 27, 2019 
 
 
 
 
 
 
 
 Organisational strategies to implement hospital pressure ulcer prevention
                                     
                                                                    - 
                                        
www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 6. … Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in Hospitals 
 Overview … Eliminating Facility-Acquired Pressure Ulcers at Ascension Health. … For example, one hospital noticed an increase in tubing-related pressure ulcers. … ulcers.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu6.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 6. … Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in Hospitals 
 Overview … Eliminating Facility-Acquired Pressure Ulcers at Ascension Health. … For example, one hospital noticed an increase in tubing-related pressure ulcers. … ulcers.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-203-fullreport.pdf
April 10, 2017 - ulcers, but it 
is important to distinguish from pressure ulcers that are “device-related.” … ulcer) and a skin assessment (to detect 
existing pressure ulcers). … Socioeconomic Status 
A study by Smith, et al., examined decubitus ulcer (pressure ulcers) as one of … Pressure ulcers in neonates and children: An NPUAP White Paper. … Guideline for prevention and 
management of pressure ulcers.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/5.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Functional Specifications … Specifications for Each Pressure Ulcer Prevention Report (continued) 
 3.5. … Report Example 
 
 
 
 Pressure Ulcer Triggers 
 Week 4 
			5/10/14 
 Week 3 
			5/17/14 
 Week 2 … Current Pressure Ulcer 
 Nurse Wound Assessment 
 For each static week:
			 
 Count the number of residents … Return to Functional Specifications Contents   
 Proceed to Next Section 
 Return to Pressure Ulcer Prevention
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/vendors.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Vendors With On-Time … Experience 
 The following EMR vendors have programmed the first On-Time Pressure Ulcer Prevention reports … Return to Pressure Ulcer Prevention
                                     
                                                                    - 
                                        
digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/citation/evaluation-ahrqs-time
January 01, 2023 - Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision … Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision … Principal Investigator 
 
 Hurd, Donna 
 
 
 
 Project Name 
 
 Evaluation of AHRQ's On-time Pressure … Ulcer Program 
 
 
 
 Technology 
 
 Clinical Decision Support System 
 
 
 
 Document Type 
 
 Journal
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/4.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Functional Specifications … Specifications for Each Pressure Ulcer Prevention Report (continued) 
 3.4. … There are nine criteria for pressure ulcer risk. … Current Pressure Ulcer 
 Nurse Wound Assessment 
 If the resident has at least one pressure ulcer for … Return to Functional Specifications Contents   
 Proceed to Next Section 
 Return to Pressure Ulcer Prevention
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides2.html
October 01, 2017 - Slide 18: Assess Current Policies (2D) 
 
 Images: A screenshot shows the Pressure Ulcer Policy Assessment … Ulcer Risk form. … Ulcer Care Plan form. … Slide 24: Sample Action Plan 
 
 Images: Two screenshots show an example of a Pressure Ulcer Prevention … Slide 25: Practice Insight 
 
 Image: A screenshot shows a table titled "Pressure Ulcer Prevention Program
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/pruprev-menu.pdf
June 02, 2025 - Ulcer Prevention Menu of Implementation Strategies 1 
On-Time Pressure Ulcer Prevention 
Menu of Implementation … Root cause analysis for new pressure ulcer development   
9. … Root cause analysis for new pressure ulcer development   
7. … Internal review to monitor residents with pressure ulcers, confirm 
awareness of nutritional status of … Root cause analysis for new pressure ulcer development   
6.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
January 06, 2018 - Review 
 
 
 
 
 
 
 
 
 
 Preventing in-facility pressure ulcers as a patient safety strategy: a systematic … Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. … Pressure ulcers are considered a  never event , but their incidence has been increasing despite effective … , and regular audit and feedback of pressure ulcer rates in ensuring intervention success. … Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-implementation-factraining-guide.pdf
June 02, 2025 - ulcers. … ulcers. … More 
accurate assessments of changes in pressure ulcers are 
needed. … what 
other wound meetings discuss residents with pressure 
ulcers. … ulcers
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/schedule.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Facilitator Training …   
 
 
 8:30 – 10:30 
 Overview of On-Time 
   
 
 
 10:30 – 10:45 
 Break 
   
 
 
 10:45 – 11:00 
 Pressure … Ulcer Prevention Reports 
   
 
 
 11:00 – 12:00 
 Nutrition Risk Reports 
   
 
 
 12:00 – 1:00 
 Lunch … Exercise—Review of the nursing home's pressure ulcer prevention program; and Debriefing 
   
 
 
 12 … Ulcer Prevention
                                     
                                                                    - 
                                        
www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 2. How will we manage change? … Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in Hospitals 
 Overview … Review of the literature to show the costliness of failing to prevent pressure ulcers. … Findings have shown that nurses generally have a "C" level of knowledge about pressure ulcers. … These goals can be related both to outcomes (e.g., a reduction in the incidence rate of pressure ulcers
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu2.html
October 01, 2014 - Preventing Pressure Ulcers in Hospitals 
 2. How will we manage change? … Previous Page Next Page 
 
 Table of Contents 
 
 Preventing Pressure Ulcers in Hospitals 
 Overview … Review of the literature to show the costliness of failing to prevent pressure ulcers. … Findings have shown that nurses generally have a "C" level of knowledge about pressure ulcers. … These goals can be related both to outcomes (e.g., a reduction in the incidence rate of pressure ulcers
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/6.html
December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention 
 
 
 
 Functional Specifications … Specifications for Each Pressure Ulcer Prevention Report (continued) 
 3.6. … ulcer, and new pressure ulcer. … Ulcer 
 Health Status # 
 
 
 
 De- creased Meal Intake + Weight Loss 
 
 
 De- creased Meal Intake … Return to Functional Specifications Contents   
 Proceed to Next Section 
 Return to Pressure Ulcer Prevention