- 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/7.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) 
 3.7. … Week Ending 
 
 
 4/6/14 
 4/13/14 
 4/20/14 
 4/27/14 
 
 
 
 
 Vital Signs 
 Number of pressure ulcers … Report Column 
 Data Source 
 Valid Input & Display 
 
 
 
 
 Vital Signs 
 
 
 Number of pressure ulcers … Wound Assessment 
 Count number of unique pressure ulcers and display count.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-impsteps.docx
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing
Implementation Steps and Timeline … Step 1: Agree To Use On-Time Pressure Ulcer Healing 
Nursing home leadership agrees to incorporate the … Ulcer Assessment and Pressure Ulcer Healing reports are in the system. … ulcers, pressure ulcer healing practices, and communication processes. … Pressure Ulcer Counts by Month Report that identifies pressure ulcer healing rates to provide feedback
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apd.html
October 01, 2017 - Ulcer Policies 
			2E: Assessing Screening for Pressure Ulcer Risk 
			2F: Assessing Pressure Ulcer … Ask them to include an example of how to score using their risk assessment scale. 
 3A: Pressure Ulcer … Ulcer Identification Pocket Pad 
			3D: The Braden Scale for Predicting Pressure Sore Risk 
			Mr. … Ulcer Knowledge Test  and staff training needs. … Instructor—facilitated group discussion 
 Education plan for pressure ulcer prevention staff education
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apc.html
October 01, 2017 - Staff Roles and Training for Your Pressure Ulcer Prevention Program 
 
 Presented by Elizabeth Ayello … Using Pressure Ulcer Risk Assessment Tools in Care Planning 
 
 Presented by Elizabeth Ayello, Ph.D., … Measuring Pressure Ulcer Rates and Prevention Practices 
 
 Presented by Karen Zulkowski, D.N.S., RN. … Risk Factors for Pressure Ulcers: Going Beyond Validated Instruments 
 
 Presented by Elizabeth Ayello … The Power of Nutrition for Pressure Ulcer Prevention 
 
 Presented by Mary D.
                                     
                                                                    - 
                                        
digital.ahrq.gov/principal-investigator/hurd-donna
January 01, 2023 - Hurd, Donna  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Evaluation of AHRQ's on-time pressure ulcer prevention program … Ulcer Program 
 
 
 
 
 
 
 
 
 
 
 
 Evaluation of AHRQ’s On-Time Pressure Ulcer Program - 2012 … Ulcer Program 
 
 
 
 
 
 
 
 
 
 
 
 Evaluation of AHRQ's On-time Pressure Ulcer Program - 2011 … Ulcer Program 
 
 
 
 
 
 
 
 
 
 
 
 Evaluation of AHRQ's On-time Pressure Ulcer Program - 2010 … Ulcer Program 
 
 
 
 
 
 
 
 
 
 
 
 Evaluation of AHRQ's On-time Pressure Ulcer Program 
 
 
 
 Description
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Successfully negotiating the change process at your hospital.
12
12
Preventing Pressure Ulcers in … Source: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit
19
19
Sustaining Change
Sustain: Changes … The Toolkit’s content draws on literature on best practices in pressure ulcer prevention and includes … CRITICAL SUCCESS FACTORS
GOAL: Decrease the overall rate of hospital-acquired pressure ulcers Stage … Preventing in-facility pressure ulcers.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/case.html
December 01, 2017 - Ulcer Prevention Program. … Drop in Pressure Ulcers with AHRQ-Funded Program 
 St. … ulcer development. … ulcer development. … ulcer outcomes.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overview.html
November 01, 2017 - ulcers, pressure ulcers that are not healing appropriately, avoidable hospitalizations, and falls—and … Evaluation studies of the On-Time pressure ulcers program have shown reductions in pressure ulcers of … Pressure ulcer prevention in long-term-care facilities: a pilot study implementing standardized nurse … Evaluation of AHRQ's On-Time pressure ulcer prevention program: a facilitator-assisted clinical decision … On-Time Topics 
 
 Pressure Ulcer Prevention . 
 Pressure Ulcer Healing .
                                     
                                                                    - 
                                        
digital.ahrq.gov/sites/default/files/docs/page/THQITStoriesHorn2010.pdf
June 16, 2021 - Nursing Home Health IT Reduces Pressure Ulcers and Increases Staff’s Job Satisfaction
       
   
      … Ulcers and Increases Staff ’s
 
Job Satisfaction
 
Pressure ulcers are a painful, 
prevalent, and preventable … Recognizing residents who 
are at high risk of 
developing pressure ulcers 
could prevent unnecessary … OnTime 
reduced the percentage of 
residents with pressure 
ulcers and led to closer bedside monitoring … Ulcers and Increases Staff ’sJob Satisfaction
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/8.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) 
 3.8. … Return to Functional Specifications Contents   
 Return to Pressure Ulcer Prevention 
 
 
 
 
 
 
 Alternate
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/pu_training-impguide.docx
October 01, 2017 - Ulcer Risk Assessment Tools in Care Planning
	Risk Factors for Pressure Ulcers: Going Beyond Validated … Ulcer Policies, Tool 2D
Assessing Screening for Pressure Ulcer Risk, Tool 2E
Assessing Pressure Ulcer … Risk Factors for Pressure Ulcers: Going Beyond Validated Instruments 
Presented by Elizabeth Ayello, … Ulcer Policies
2E: Assessing Screening for Pressure Ulcer Risk
2F: Assessing Pressure Ulcer Care Planning … Identification Pocket Pad
3D: The Braden Scale for Predicting Pressure Sore Risk
Mr.
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar4_pu_skinassesst_final.pdf
April 01, 2011 - • Provide data needed to calculate pressure 
ulcer incidence and prevalence.
• Stratify risk. … – Patients with existing pressure ulcers are at risk 
for more. … For each patient, record—
• Whether he/she has pressure ulcers
• How many pressure ulcers he/she has … Preventing pressure ulcers in hospitals: a 
toolkit for improving quality of care. … – Tool 3A: Pressure Ulcer Prevention Pathway for Acute Care
– Tool 3C: Pressure Ulcer Identification
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/evaluation-suitability-root-cause-analysis-frameworks-investigation-community-acquired
June 16, 2021 - ulcers . … In hospital and long-term care settings, pressure ulcers are considered preventable complications, but … August 14, 2019 
 
 
 
 
 
 
 
 Medical device-related pressure ulcers: a systematic review and meta-analysis … October 8, 2016 
 
 
 
 
 
 
 
 Wound-care teams for preventing and treating pressure ulcers. … November 12, 2014 
 
 
 
 
 
 
 
 Preventing in-facility pressure ulcers as a patient safety strategy
                                     
                                                                    - 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
January 01, 2024 - Ulcer	Communication	167	2.2%
	Pressure Ulcer	Data	*	*
	Pressure Ulcer	Environment	29	0.4%
	Pressure … 0.3%
	Pressure Ulcer	Staff qualifications	184	2.4%
	Pressure Ulcer	Supervisor/Support	*	*
	Pressure … Ulcer	Under 18	Female	No Harm	175	11.8%
	Pressure Ulcer	Under 18	Female	Severe Harm	*	*
	Pressure Ulcer … *	*
	Pressure Ulcer	UNK	Female	Unknown Harm	*	*
	Pressure Ulcer	UNK	Male	Mild Harm	63	75.0%
	Pressure … Ulcer	UNK	Male	Moderate Harm	*	*
	Pressure Ulcer	UNK	Male	No Harm	17	20.2%
	Pressure Ulcer	UNK	Male
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/reviews.html
August 01, 2018 - Versus Institutional Care 
 Nonpharmacologic Interventions for Agitation and Aggression in Dementia 
 Pressure … Ulcer Risk Assessment and Prevention: Comparative Effectiveness 
 Pressure Ulcer Treatment Strategies
                                     
                                                                    - 
                                        
pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - ulcers 
• New sacrococcygeal pressure ulcer that progressed to stage 4 during LTCH stay
• Pressure ulcer … ulcers
• Stage 2 nasal pressure ulcer associated with face mask
• Deep tissue injuries related to ace … • Sacral pressure ulcer
• Stage 1 coccygeal pressure ulcer
• Stage 1 facial pressure ulcer associated … with BiPAP mask 
• Stage 1 pressure ulcer heel
• Stage 1 pressure ulcer on sacrum
• Stage 1 sacral pressure … ulcer
Page 9 of 9
• Stage 2 pressure ulcer of sacrum
• Stage 2 pressure ulcer of sacrum
• Suspected
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury
July 07, 2021 - ulcer development. … July 14, 2021 
 
 
 
 
 
 
 
 Accuracy of pressure ulcer events in US nursing home ratings. … June 9, 2021 
 
 
 
 
 
 
 
 Medical device-related pressure ulcers: a systematic review and meta-analysis … October 24, 2018 
 
 
 
 
 
 
 
 Organisational strategies to implement hospital pressure ulcer prevention … ulcers: a systematic review and documentary analysis.
                                     
                                                                    - 
                                        
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/2.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) 
 3.2. … Return to Functional Specifications Contents   
 Proceed to Next Section 
 Return to Pressure Ulcer Prevention
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/837890/psn-pdf
August 24, 2022 - Accuracy of pressure ulcer events in US nursing home
ratings. … Accuracy of pressure ulcer events in US nursing home ratings. … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings
All nursing homes … This study compared seven years of
self-reported pressure ulcer data with claims-based data for pressure … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings
https://psnet.ahrq.gov
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/841476/psn-pdf
December 14, 2022 - Barriers and facilitators to reporting medical device-
related pressure ulcers: a qualitative exploration … Barriers and facilitators to reporting medical device-related
pressure ulcers: a qualitative exploration … https://psnet.ahrq.gov/issue/barriers-and-facilitators-reporting-medical-device-related-pressure-ulcers … Interviews with experts in hospital-acquired pressure ulcers revealed four
domains related to reporting … https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ratings
https://psnet.ahrq.gov