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281. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
     January 29, 2008 - ulcer (bed sores); or postoperative sepsis (blood infection). … Decubitus ulcer 5. Failure to rescue 6. Foreign body left during procedure 7. … • Monitoring errors, such as bedsores, failure to rescue, and patient falls. … ulcer monitoring error • Increased checking of inpatients for decubitus ulcers • Monitoring … forms or behavioral checklists • Decubitus ulcer incidence rate feedback • Supervisor praise

282. 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?

283. No More CAUTI: Preventing Catheter-Associated Urinary Tract Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-preventing-cauti-transcript.html
     November 01, 2015 - Finally, Liz served as a national mentor to 2 fellows in the project protect infection prevention fellowship … Today, we're going to be talking specifically about the education component in your CAUDI prevention … For a lot of people, part of their CAUDI prevention program is not only looking at appropriate indication … Again, this is a good visual of we're not talking about just a little stage 1 or stage 2 pressure ulcer … The catheter itself can actually cause pressure ulcers just as much as incontinence can.

284. No More CAUTI: Preventing Catheter-Associated Urinary Tract Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-transcript.html
     December 01, 2017 - Finally, Liz served as a national mentor to 2 fellows in the project protect infection prevention fellowship … Today, we're going to be talking specifically about the education component in your CAUDI prevention … For a lot of people, part of their CAUDI prevention program is not only looking at appropriate indication … Again, this is a good visual of we're not talking about just a little stage 1 or stage 2 pressure ulcer … The catheter itself can actually cause pressure ulcers just as much as incontinence can.

285. Recommendations to Improve Children's Health Care Quality Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/policymakers/chipra/pubs/background-2012/backgrndapb.html
     December 01, 2012 - illness (CAHMI) 6,3   0081 Pediatric Global Health Scale (CHOP) N/A 7,3.75   Prevention … 4.5,2   0010 Postoperative wound dehiscence (PDI 11) (AHRQ) 6,3 5,3.75   0005 Pressure … ulcer rate (PDI 2) (AHRQ) 7,3 6.5,3.75   0004 Accidental puncture or laceration (PDI 1

286. 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/ereports.html
     September 01, 2017 - Current clinical conditions contributing to transfer risk: use of oxygen, catheter or ostomy, any pressure … ulcer other than stage I, fall risk, late-loss activities of daily living (ADL) score greater than or … Presence of stage II or greater pressure ulcer. Fall risk or previous fall in last 90 days. … ulcer, and two medical conditions, cellulitis and hypertension, would trigger Rule 2. … teams can use the report to track patterns, follow up on areas of decline, and monitor progress of new prevention

287. Introduction to the Quality Indicators Best Practices Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
     June 02, 2025 - Best practices forms exist for the following 14 PSIs: • PSI 03 Pressure Ulcer Rate • PSI 05 Retained … 03 Neonatal Blood Stream Infection Rate • PDI 01 Accidental Puncture or Laceration Rate • PDI 02 Pressure … Ulcer Rate • PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count • PDI 05 Iatrogenic

288. AHRQ Quality Indicators Fact Sheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a1a_pdi_pdifactsheet.pdf
     October 01, 2015 - Each PDI in the composite is amenable to prevention through system-level related structures and processes … Infection Rate 25.18 0478 2013 PDI 01 Accidental Puncture or Laceration Rate 0.46 0344 2012 PDI 02 Pressure … Ulcer Rate 0.27 0337 2015 PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count N/A*

289. Fact Sheet on Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
     October 01, 2015 - Each PDI in the composite is amenable to prevention through system-level related structures and processes … Infection Rate 25.18 0478 2013 PDI 01 Accidental Puncture or Laceration Rate 0.46 0344 2012 PDI 02 Pressure … Ulcer Rate 0.27 0337 2015 PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count N/A*

290. Declines in Hospital Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-decline.pdf
     June 02, 2025 - Infections +CLABSI - Central Line-Associated Bloodstream Infection Falls Obstetric Adverse Events Pressure … Ulcers Surgical Site Infections Ventilator- Associated Pneumonias 0% (Post-op) Venous

291. Final Progress Report: Accountability and Health Safety – A Statewide Approach (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/thorpe-rask-report.pdf
     January 01, 2024 - Enables the user to evaluate the organization’s falls prevention program, develop an improvement plan … Hospital Acquired Pressure Ulcers Self-Assessment: • Improvement Plan Documentation Form • Reassessment … ulcers, develop an improvement plan, and evaluate actions completed. … Ulcer Self-Assessment • Diabetes Survey • DVT Policy and Procedure Survey • Failure Mode Effects … Ulcer Self-Assessment, Diabetes Survey, and DVT Policy and Procedure Survey.

292. A New Model of Tracheostomy Care: Closing the Research–Practice Gap (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Clair.pdf
     January 01, 2004 - The WRAMC Department of Nursing is presently developing similar evidence-based procedures for pressure … ulcer prevention, deep vein thrombosis prophylaxis, and for enteral feeding. … Ongoing and future projects funded through the TriService Nursing Research Program (TSNRP) include pressure … ulcer prevention, deep vein thrombosis prophylaxis, and enteral feeding precautions to reduce aspiration

293. Declines in Hospital-Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
     January 01, 2019 - CLABSI+ -6% Clostridioides difficile Infections -37% Falls -5% Obstetric Adverse Events -3% Pressure … Ulcers Surgical Site Infections Ventilator- Associated Pneumonias -13% Venous Thrombo-

294. Background for AHRQ Quality Indicators
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pptx
     October 01, 2015 - Ulcer Rate PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count PDI 05 Iatrogenic Pneumothorax … ulcer) Denominator = population at risk (e.g., hospitalized patients) Observed rate = numerator/denominator … 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) Tool A.2 Slide ‹#› Pediatric Toolkit for Using the AHRQ Quality

295. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2023-adverse-event-data-report.pdf
     January 01, 2023 - https://www.ahrq.gov/patient-safety/settings/index.html 2 Centers for Disease Control and Prevention … xx Office of Disease Prevention and Health Promotion, "National Action Plan for Adverse Drug Event Prevention

296. Patients Safer as Hospital-Acquired Conditions Decline (Data Graphic) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-graphic-2014.pdf
     January 01, 2014 - hospital-acquired conditions (HACs) such as adverse drug events, healthcare-associated infections, and pressure … ulcers have been prevented in hospital patients.

297. Table A: Indicator Rates for the HCBS and Full Medicaid Populations (Rates of Admission per 100,000 Persons) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/oirtab.html
     December 01, 2012 - Composite: ACSC Acute Conditions 6,913 2,846 Composite: ACSC Overall 17,971 7,139 Pressure … Ulcer 3,067 1,136 Injurious Falls 287 105 Source: Schultz, et al., 2012 (see

298. Making Health Care Safer II, Executive Summary (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
     March 01, 2013 - ulcers. … Examples include most fall prevention programs, VTE prophylaxis, and medical history abbreviations … Examples include some fall prevention programs, many clinical pharmacist interventions, and participation … ulcers; and PSPs designed to improve the overall system or to address multiple patient safety targets … ulcers, and other nursing sensitive outcomes (other than mortality); in-depth review Common/High

299. Discussion | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-discuss.html
     November 01, 2017 - 0.035–0.070) 0.055 OBAE $602 (-$578–$1,782) $3,271 0.005 (0.003–0.013) 0.0015 Pressure … Ulcers $14,506 (-$12,313–$41,326) $18,537 0.041 (0.013–0.093) 0.072 SSI $28,219 ($18,237 … In all other HACs, while we observed some increase (CAUTI) and some decrease (ADE, pressure ulcers) compared … At the same time that prevention efforts were ramping up, the CDC National Healthcare Safety Network … Second, prevention efforts may have been more effective at reducing the risk of developing these HACs

300. Fact Sheet on Patient Safety Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
     October 01, 2015 - Each PSI in the the PSI 90 composite is amenable to prevention through system-level related structures … Year PSI 02 Death Rate in Low-Mortality Diagnosis- Related Groups (DRGs) 0.32 0347 2012 PSI 03 Pressure … Ulcer Rate 0.50 PSI 04 Death Rate Among Surgical Inpatients with Serious Treatable Complications