- 
                                        
digital.ahrq.gov/sites/default/files/docs/citation/r01hs015274-carayon-final-report-2009.pdf
January 01, 2009 - urinary tract 
infections, ventilator bundle compliance, self-extubations  and percent reintubations, pressure … ulcers  and skin erosion, percentage of antibiotics  given in one hour or less, a nd compliance with
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/related_files/disabilities-quality-improvement-outcomes_executive.pdf
October 01, 2012 - including:
8
• Preventive dental care
• Preventive medical care 
• Urinary tract infections
• Pressure … ulcers
• Diabetes and diabetic complications
• Pneumonia
• Asthma
• Gastroenteritis
• Hypertension
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-datasources.pdf
December 01, 2020 - infections; seven types of adverse events associated with surgery; 
patient falls; and hospital-acquired pressure … ulcers. … events associated with the hospital stay and not present on hospital admission 
(inpatient falls and pressure … ulcers).
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/pdf/dementia-nursing-home-characteristics_research-protocol.pdf
November 03, 2011 - Functional decline 
○ Cognitive decline 
○ Symptoms of depression 
○ Falls 
○ Morbidities (e.g., pressure … ulcers) 
○ Hospitalization 
○ Mortality 
○ Sleep quality 
 
Psychosocial outcomes for people with
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2023qdr-data-sources.pdf
December 01, 2023 - Healthcare-associated Infection (HAI) 
Patients with one or more falls during stay Fall 
Stays with one or more pressure … ulcer adverse events Pressure Ulcer 
Venous thromboembolism/pulmonary embolism 
(VTE/PE) not related
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/2024-01/oleary-report.pdf
January 01, 2024 - hospitalized general 
medical patients, including adverse drug events, hospital acquired infections, pressure … ulcers, 
and falls.
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/pdf/cultural-competence_research-protocol.pdf
July 09, 2014 - secondary to the disability such as urinary tract infections, asthma, obesity, 
hypertension, and pressure … ulcers.5 
As the overlapping circles in Figure1 suggest, there are also interventions 
encompassed
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/2025-04/schiff-mcnutt-report.pdf
January 01, 2025 - measures failure to diagnose.
4
Although, for each of these AHRQ 20 “sentinel complications” (e.g., decubitus … ulcer, iatrogenic 
pneumothorax, post-op septicemia, accidental puncture/laceration), timely diagnosis
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/depression-horizon-scan-high-impact-1412.pdf
December 01, 2014 - #05 DEPRESSION
AHRQ Healthcare Horizon Scanning System – Potential 
High-Impact Interventions Report 
 
Priority Area 05: Depression and Other Mental Health 
Disorders  
 
Prepared for:  
Agency for Healthcare Research and Quality 
U.S. Department of Health and Human Services  
540 Gaither Road 
Rockville, MD… 
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/depression-horizon-scan-high-impact-1406.pdf
June 01, 2014 - #05 DEPRESSION
AHRQ Healthcare Horizon Scanning System – Potential 
High-Impact Interventions Report 
 
Priority Area 05: Depression and Other Mental Health 
Disorders  
 
Prepared for:  
Agency for Healthcare Research and Quality 
U.S. Department of Health and Human Services  
540 Gaither Road 
Rockville, MD… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/publications/files/confidreportguide_1.pdf
March 01, 2016 - in hospitals, as well as related component 
measures, such as an A1c value less than 8 percent, and pressure … ulcer rate, for primary 
care clinicians and hospitals, respectively
                                     
                                                                    - 
                                        
digital.ahrq.gov/sites/default/files/docs/page/sustainability-partnerships-and-teamwork-in-health-it-implementation.pdf
December 01, 2012 - through the “‘On-Time’ 
Quality Prevention Program for Long-Term Care” and found it helped reduce 
pressure … ulcers. … id=1174&type=seg), 
❍❍ “Preventing Bed Sores,” featuring Dr. … through 
the “‘On-Time’ Quality Prevention Program for Long-Term Care” and 
found it helped reduce pressure … ulcers.
                                     
                                                                    - 
                                        
www.uspreventiveservicestaskforce.org/home/getfilebytoken/T6Tquunynv3tWM65BFash2
October 01, 2015 - Behavioral and Pharmacotherapy Interventions for Tobacco Smoking
Cessation in Adults, Including Pregnant Women: U.S. Preventive
Services Task Force Recommendation Statement
Albert L. Siu, MD, MSPH, for the U.S. Preventive Services Task Force*
Description: Update of the 2009 U.S. Preventive Services Task
Force (USPSTF)… 
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/related_files/surveillance-report-3-nonopioid-pharm-chronic-pain.pdf
July 01, 2022 - Systematic Review on Nonopioid Pharmacologic Treatments for Chronic Pain: Surveillance Report 3
Systematic Review on Nonopioid 
Pharmacologic Treatments for Chronic 
Pain: Surveillance Report 3 
Literature Update Period: January 2022 through April 1, 2022 
Background and Purpose 
This is the third surveillance repor… 
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/playbook_revised.pdf
April 01, 2022 - CLINICAL INDICATIONS for use of external catheters:32 
• Stage III or Stage IV or unstageable pressure … ulcers  
• Moderate to severe incontinence-associated dermatitis 
• Daily (not hourly) measurement of
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/functional-limitations-horizon-scan-high-impact-1306.pdf
June 01, 2013 - several experts thought that besides providing psychological benefits, 
this intervention might improve pressure … ulcer incidence as well.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/2024-11/gregory-report.pdf
January 01, 2024 - they were deemed to be not relevant for this population (PSI #2: 
Death in low-mortality DRGs, PSI #3: Decubitus … ulcer, PSI #4: Failure to rescue, PSI #6: Iatrogenic 
pneumothorax, PSI #7: Selected infections due
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/pdf/rapid-reviews-end-user_white-paper.pdf
April 01, 2016 - considered to be of general interest, we selected 4 topics: venous 
thromboembolism, fecal DNA testing, pressure … ulcers, and methicillin-resistant staphylococcus 
aureus.
                                     
                                                                    - 
                                        
www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/hisph-slides-pt3.html
May 01, 2018 - restrained daily can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions.
                                     
                                                                    - 
                                        
effectivehealthcare.ahrq.gov/sites/default/files/related_files/wheelchair-service_disposition-comments.pdf
January 01, 2012 - and equipment is discrete 
and separate from funds to reimburse confounding medical 
conditions (i.e. pressure … ulcers, respiratory/pulmonary 
conditions, depression, falls and related complications) and 
personal