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301. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhac2013-ap4.html
     December 01, 2014 - Ulcers 250,000 50% 50% 25% 62,500 $17,000 .072 $1,062,500,000 4,525 Surgical … 17.4% 1,040,500 NA NA $9,141,150,000 35,647 * Additional costs per HAC for Falls and Pressure … Ulcers were modified in 2012 from earlier higher projections. … been wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure … ulcer, rather than on the incremental cost due to the HAC.   18.

302. Table 10: Outcome Indicators by Selected Home and Community-Based Services 1915(c) Waiver Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab10.html
     February 01, 2023 - Composite: ACSC Overall Yes 22,422 20,395 25,160 No 18,138 19,018 17,666 Pressure … Ulcer Yes 5,006 4,208 4,833 No 2,960 3,348 3,127 Injurious Falls Yes 307 … 7,607 Composite: ACSC Overall 20,384 19,444 14,877 19,094 19,184 20,443 Pressure … Ulcer 4,195 4,249 2,476 3,395 3,286 3,764 Injurious Falls 388 259 218

303. Board and Senior Leadership PowerPoint Presentations on the Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
     October 01, 2015 - ulcer) • Denominator = population at risk (e.g., hospitalized patients) • Observed rate = numerator … ulcer in any secondary diagnosis field among cases meeting the inclusion and exclusion rules for the … • Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02) http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)� How can the AHRQ PDIs be used in�quality assessment?

304. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.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.

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

306. Table 12: Outcome Indicators by Use of Selected Home and Community-Based Services 1915(c) Waiver Services, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab12.html
     February 01, 2023 - Composite: ACSC Overall Yes 26,515 17,685 7,028 No 18,855 19,300 20,127 Pressure … Ulcer Yes 6,274 3,455 1,049 No 3,338 3,486 3,662 Injurious Falls Yes 369 … 7,404 Composite: ACSC Overall 6,233 33,102 8,819 20,714 16,992 19,479 Pressure … Ulcer 1,013 6,793 2,359 3,765 2,949 3,511 Injurious Falls 157 543 138

307. C1 Prioritization Worksheet (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
     June 02, 2025 - 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

308. Psi90 Factsheet Faq (pdf file)
     qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf
     August 31, 2016 - This “modified version” of PSI 90 component indicator includes the following:  PSI 03 Pressure Ulcer … Ulcer Rate 0.033006 0.059841 81.3% PSI 06 Iatrogenic Pneumothorax Rate 0.075069 0.053497 -28.7% … ulcer treatment Debridement of a pressure ulcer and/or surgical skin flap procedure during the hospitalization … when the pressure ulcer developed, due to tissue damage. … PSI 03 180-day hospital readmission for a pressure ulcer related complication Readmission to an

309. Table 9: Outcome Indicators by Selected Home and Community-Based Services Medicaid State Plan Services Offered, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab9.html
     February 01, 2023 - Overall Yes 18,922 20,115 18,052 19,228 No 28,131 18,583 22,752 19,363 Pressure … Ulcer Yes 3,471 3,655 3,237 3,421 No 3,873 3,358 4,221 4,253 Injurious … Composite: ACSC Overall 19,083 19,110 16,427 19,636 23,560 27,103 21,664 20,810 Pressure … Ulcer 3,504 3,473 2,888 3,575 2,944 4,236 4,000 3,773 Injurious Falls 285

310. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - It is more difficult for staff to identify which residents are at risk for a fall or pressure ulcer or … ulcers, pressure ulcers that are not healing appropriately, falls, and preventable hospitalizations. … For example: Pressure Ulcer Prevention has been pilot tested in more than 50 nursing homes across … On-Time pressure ulcer prevention reports were integrated into day-to-day workflow. … Pressure Ulcer Healing, Falls, and Avoidable Hospitalization reports and worksheets have been tested

311. Clinical Practice Guidelines Archive | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/guidelines/archive.html
     July 01, 2018 - Pressure Ulcer Prevention Clinical Guide / Quick Reference Guide Consumer Version: English / … Pressure Ulcer Treatment Clinical Guide / Quick Reference Guide Consumer Version: English / Spanish

312. Table 19F: HCBS Population Ages 18-64 Without I/DD or SMI | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19f.html
     March 01, 2023 - 5,990 6,632 Composite: ACSC Overall 23,094 19,763 20,681 21,282 21,204 19,420 Pressure … Ulcer 6,082 4,303 4,919 4,872 4,765 5,535 Injurious Falls 173 119 141 130 … 5,861 6,673 6,037 6,455 Composite: ACSC Overall 20,343 22,153 21,427 18,076 Pressure … Ulcer 4,499 5,846 4,870 5,072 Injurious Falls 140 131 131 168 Notes

313. Table 19G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19g.html
     March 01, 2023 - 12,136 Composite: ACSC Overall 32,463 23,973 25,306 28,599 25,757 29,466 Pressure … Ulcer 4,845 3,916 4,034 4,473 4,279 3,822 Injurious Falls 694 450 520 525 … 12,380 10,227 12,540 Composite: ACSC Overall 24,470 31,390 25,983 29,126 Pressure … Ulcer 4,169 4,242 4,328 3,449 Injurious Falls 498 580 497 653 Notes

314. Table 19E: SMI Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19e.html
     March 01, 2023 - 6,924 7,208 Composite: ACSC Overall 20,218 17,976 20,084 17,046 19,215 17,075 Pressure … Ulcer 3,124 2,492 3,084 2,232 2,819 2,301 Injurious Falls 297 218 268 212 … 6,471 8,020 7,037 6,881 Composite: ACSC Overall 17,757 20,393 19,476 16,171 Pressure … Ulcer 2,658 2,731 2,846 2,191 Injurious Falls 239 247 236 260 Notes

315. Table 19D: I/DD Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19d.html
     March 01, 2023 - 3,685 2,830 Composite: ACSC Overall 6,401 5,144 6,083 4,903 6,049 4,408 Pressure … Ulcer 1,887 1,225 1,703 1,115 1,573 1,084 Injurious Falls 88 67 77 69 79 … 3,503 3,242 3,720 2,668 Composite: ACSC Overall 5,768 5,111 6,087 4,163 Pressure … Ulcer 1,543 1,223 1,589 999 Injurious Falls 77 67 77 63 Notes:  

316. Table 19C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19c.html
     March 01, 2023 - 4,435 3,912 Composite: ACSC Overall 14,847 12,685 13,750 12,591 14,039 10,413 Pressure … Ulcer 3,144 1,922 2,311 2,203 2,306 2,125 Injurious Falls 114 46 72 55 58 … 4,284 4,429 4,470 3,725 Composite: ACSC Overall 13,151 13,631 14,134 9,746 Pressure … Ulcer 2,071 2,713 2,345 1,945 Injurious Falls 68 59 59 92 Notes:  

317. Table 19B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19b.html
     March 01, 2023 - 8,456 8,118 Composite: ACSC Overall 25,741 19,330 21,845 20,450 21,888 19,402 Pressure … Ulcer 4,659 3,573 4,127 3,570 4,133 3,186 Injurious Falls 476 335 399 346 … 8,162 8,798 8,469 8,012 Composite: ACSC Overall 20,856 22,154 22,042 18,402 Pressure … Ulcer 4,014 3,688 4,171 2,882 Injurious Falls 384 365 381 366 Notes

318. Table 19A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19.html
     March 01, 2023 - 7,387 7,164 Composite: ACSC Overall 23,095 17,584 19,743 18,467 19,802 17,363 Pressure … Ulcer 4,291 3,139 3,655 3,225 3,647 2,945 Injurious Falls 388 259 314 272 … 7,138 7,741 7,427 6,977 Composite: ACSC Overall 18,821 20,092 19,980 16,312 Pressure … Ulcer 3,501 3,452 3,695 2,655 Injurious Falls 301 291 297 299 Notes

319. Table 11: Outcome Indicators by Use of Selected Home and Community-Based Services Medicaid State Plan Services, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab11.html
     February 01, 2023 - Overall Yes 14,177 28,212 18,788 9,372 No 19,380 19,211 19,521 20,716 Pressure … Ulcer Yes 2,730 11,421 3,150 1,840 No 3,506 3,461 3,696 3,731 Injurious … Composite: ACSC Overall 50,783 40,549 9,972 20,001 18,997 10,923 20,108 19,218 Pressure … Ulcer 12,696 8,204 883 4,475 3,415 1,644 3,729 3,459 Injurious Falls 469

320. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
     November 19, 2015 - About 40 percent of this reduction is from adverse drug events, about 28 percent from pressure ulcers … 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 7 2010 baseline data … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC. 13 Saving Lives and Saving Money: Hospital-Acquired