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401. The impact of the use of employee functional flexibility on patient safety. | PSNet
     psnet.ahrq.gov/issue/impact-use-employee-functional-flexibility-patient-safety
     January 12, 2022 - examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure … ulcers . … Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure … ulcers, but this effect was moderated when coworker support within the unit was high.

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46027/psn-pdf
     July 02, 2019 - with Hospital Compare data on hospital- acquired conditions like health care–associated infections, pressure … ulcers, or falls. … https://psnet.ahrq.gov/primer/health-care-associated-infections https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42895/psn-pdf
     December 18, 2014 - Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national … https://psnet.ahrq.gov/glossary-0#glossary-heading-term-73754 https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero

404. Chartbook on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2020.pdf
     January 01, 2020 - There are no detailed sections for the Perinatal, Pressure Ulcer, or Surgery or Anesthesia EVENT TYPES … No harm was reported for more than one-quarter (18,632 / 73,155; 25.5%) of Pressure Ulcer Incidents … This was unexpected, as pressure ulcers, like HAIs and venous thromboembolism (VTE), result in harm … Ulcer A pressure ulcer that, on admission, was at stage/category III or stage/category IV or was … /category I or stage/category II A pressure ulcer whose most advanced stage is unknown A mucosal

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42423/psn-pdf
     July 17, 2013 - that policy changes are required to prevent specific adverse events, such as postoperative sepsis and pressure … ulcers. … https://psnet.ahrq.gov/issue/postoperative-sepsis-united-states https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero

406. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/transfer.html
     September 01, 2017 - DNR,DNH, MOLST, or POLST Order in Place Oxygen Therapy Catheter or Ostomy Present Stage II or > Pressure … Ulcer Fall Risk Late-Loss ADL Score ≥12 Cognitive Impairment Medical Conditions ** High-Risk

407. Patient Self-Management | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/patient-self-management.html
     AHRQ Research Findings Support Effort to Reduce Pressure Ulcers in Virginia Engaging Patients and

408. Telewound Care Network (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/uc1hs015359-bryant-final-report-2008.pdf
     January 01, 2008 - ulcers each year. … Cost to treat a pressure ulcer, a common chronic wound, is estimated to range from $4,000 to $40,000 … Study patients included inpatients and outpatients with pressure ulcers of stage II, III, or IV, plus … Agostini, JV, Baker, D., and Bogardus, S.T.; “Prevention of Pressure Ulcers in Older Patients,” from … “Osteomelitis related to pressure ulcers: the cost of neglect,” Adv Skin Wound Care. 2000 Jan-Feb: 12

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73350/psn-pdf
     June 02, 2021 - pressure-injury-prevention-hospitals-training-program https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42083/psn-pdf
     March 13, 2013 - health care–associated infections and surgical complications, bundled interventions to reduce falls and pressure … ulcers, and interventions to decrease medication errors and improve hand hygiene—are all considered … inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero

411. Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/prevention.html
     Preventive Services to People with Disabilities AHRQ Research Findings Support Effort to Reduce Pressure … Ulcers in Virginia Celebrating the 40th Anniversary of the U.S.

412. Resources by Safety Topic | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/type-harm.html
     September 01, 2025 - Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure … Ulcers Readmissions Sepsis Surgical Safety Transitions in Care Venous Thromboembolism Diagnostic Safety … Back to Contents Pressure Ulcers AHRQ Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving … Quality of Care This resource assists hospital staff in implementing effective pressure ulcer prevention

413. C2 Prioritization Worksheet Example (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c2_pdi_prioritizationworksheetexample.pdf
     June 02, 2025 - N PDI 01 Accidental Puncture 0.3 0.6 1 $41,204 $ 41,204 N 9 9 9 Y Y Y Y Y PDI 02 Pressure … Ulcer 0.0 0.2 0 $85,344 $ - N 6 6 6 Y Y Y Y Y PDI 05 Iatrogenic Pneumothorax

414. Long-Term Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/long-term-care.html
     AHRQ Research Findings Support Effort to Reduce Pressure Ulcers in Virginia AHRQ’s Safety Program

415. Patient Safety and Adverse Events, 2011 and 2014 (pdf file)
     hcup-us.ahrq.gov/reports/statbriefs/sb237-Patient-Safety-Adverse-Events-2011-2014.pdf
     January 01, 2014 - The PSIs focus on adverse events during the hospital stay (such as pressure ulcers), complications associated … Ulcer Rate Wounds caused by unrelieved pressure on the skin usually around bony prominences PSI … ulcers (23.1 percent decrease). … ulcers (69.1 percent), death rate in low-mortality DRGs (68.9 percent), and iatrogenic pneumothorax … The 10 risk-adjusted rates contributing to PSI 90 are as follows:  Pressure Ulcer Rate (PSI 03) 

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849317/psn-pdf
     May 24, 2023 - root-cause-analysis-identify-contributing-factors-development-hospital-acquired-pressure https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33651/psn-pdf
     June 01, 2007 - In certain categories, particularly with something like pressure ulcers, there is almost certainly underreporting … Are pressure ulcers not being discovered, or are they not being correctly staged so that people know … ulcers and other errors. … One was a facility that had a high number of pressure ulcers. … As a result of that really concerted effort to identify pressure ulcers, they have identified many ulcers

418. In Conversation with...Diane Rydrych, MA | PSNet
     psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
     February 26, 2025 - In certain categories, particularly with something like pressure ulcers, there is almost certainly underreporting … Are pressure ulcers not being discovered, or are they not being correctly staged so that people know … ulcers and other errors. … One was a facility that had a high number of pressure ulcers. … As a result of that really concerted effort to identify pressure ulcers, they have identified many ulcers

419. Evidence-based Practice Center Systematic Review Protocol (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/pdf/venous-ulcers-treatment_research-protocol.pdf
     September 13, 2012 - high relevance to morphologically similar ulcers found in patients with diabetes, arterial disease, pressure … ulcers, postsurgical chronic wound ulcers, and ulcers consequent to internal diseases. … ankle brachial index less than 0.6 or a toe brachial index less than 0.5 or other clinical criteria), pressure … ulcers, postsurgical ulcers, and neuropathic ulcers … ulcers, post-surgical ulcers, and neuropathic ulcers.

420. Final Progress Report: Safety Outcomes of Obese Residents in US Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2024-05/felix-report.pdf
     January 01, 2024 - Being underweight increased the odds of experiencing a fall, fall with injury, or pressure ulcer but … ulcers/ injuries and UTIs. … Association of overweight and obesity with the prevalence and incidence of pressure ulcers: A systematic … The paradox of obesity in pressure ulcers of critically ill patients. … Obesity and pressure ulcers among nursing home residents. Medical Care. 2013;51(6):478-86. 44.