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301. 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

302. Staff Presentation Template (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c3_combo_staffpresentation.pdf
     July 01, 2004 - with specific information tailored to the example indicator: The indicator that we have chosen, Pressure … Ulcers (PSI 03), is important to our patients because improvement on this indicator may reduce: • … Tool C.3 DELETE THIS SLIDE BEFORE PRESENTATION – In this example, we will examine the rates of Pressure … Ulcers (PSI 03) for this particular hospital performed over time … Ulcers (PSI 03) for this particular hospital performed over time

303. Indwelling Urinary Catheter Indications Facilitator Notes (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
     April 01, 2022 - strict immobility post-procedure, and urinary incontinence contaminating open (stage 3 or stage 4) pressure … ulcers. … ulcers and weakness from less walking. … ulcers. … ulcers.

304. CAUTI Learning From Defects Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.docx
     April 01, 2022 - · Comfort care · Urological/perineal procedure · Stage 3 or greater pressure ulcer in perineal area with

305. Peterson Regional Medical Center Uses AHRQ's CUSP and Hospital Survey to Advance Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201419.html
     November 01, 2014 - protocols for communication, teamwork, and leadership to address other patient safety issues such as falls prevention … , medication safety, urinary tract infection, and pressure ulcers.  

306. Learn From Defects Tool Worksheet: Catheter-Associated Urinary Tract Infection (CAUTI) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-learning-from-defects-revised.pdf
     April 01, 2022 - � Comfort care � Urological/perineal procedure � Stage 3 or greater pressure ulcer in perineal area

307. 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

308. Table 8B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8b.html
     February 01, 2023 - 19,884   Min 8,723 s s s s   Max 39,914 44,860 74,074 109,091 s Pressure … Ulcer 3,472 6,789 3,352 1,525 3,397   Min 1,663 s s s s   Max 7,916 … 11,656 7,935 10,256   Max 34,059 41,284 22,863 50,576 50,856 32,463 44,228 Pressure … Ulcer 4,095 3,804 3,300 3,854 5,806 3,982 3,777   Min 1,775 1,548 1,208

309. Table 8C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8c.html
     February 01, 2023 - 12,152   Min 3,503 s s s s   Max 29,139 28,882 33,333 57,143 s Pressure … Ulcer 2,008 3,468 1,508 1,305 1,829   Min s s s s s   Max 6,520 … s s 3,109 s   Max 19,830 35,256 29,840 68,293 96,970 25,549 36,882 Pressure … Ulcer 2,944 1,761 2,317 1,619 2,209 2,206 2,570   Min 509 377 567 s s

310. Table 8E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8e.html
     February 01, 2023 - 15,175   Min 9,170 s s s s   Max 49,738 48,185 50,000 88,889 s Pressure … Ulcer 2,658 3,470 2,422 1,613 1,534   Min s s s s s   Max 9,819 … s 5,975 8,746   Max 44,606 51,218 33,445 80,351 102,632 52,215 42,172 Pressure … Ulcer 2,710 2,665 2,098 4,545 9,171 2,740 2,569   Min 435 648 436 s s

311. Table 8G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8g.html
     February 01, 2023 - 23,974   Min 13,559 s s s s   Max 51,766 57,143 95,238 65,509 s Pressure … Ulcer 3,793 7,856 3,285 1,307 3,856   Min s s s s s   Max 8,542 … 11,836 13,626 18,523   Max 54,523 48,091 s 49,755 49,129 42,431 53,347 Pressure … Ulcer 4,221 4,180 s 3,748 5,699 4,229 4,086   Min 1,310 1,479 s 1,213

312. Table 8A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8.html
     February 01, 2023 - 17,845   Min 7,027 9,302 s s s   Max 36,997 40,253 41,379 51,572 s Pressure … Ulcer 3,134 5,690 2,837 1,476 2,984   Min 1,506 s s s s   Max 6,772 … 11,836 6,378 8,163   Max 29,607 39,709 25,788 49,755 49,129 29,454 42,207 Pressure … Ulcer 3,751 3,329 2,863 3,748 5,699 3,509 3,506   Min 1,805 1,374 1,106

313. Table 8D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8d.html
     February 01, 2023 - 4,484   Min 2,636 s s s s   Max 10,521 14,248 15,129 53,571 s Pressure … Ulcer 1,283 2,251 1,420 1,057 894   Min s s s s s   Max 3,665 6,218 … 7,984 s 1,713 s   Max 9,546 12,167 7,955 38,424 95,652 9,389 12,785 Pressure … Ulcer 1,410 1,397 1,218 3,471 10,593 1,460 1,308   Min 289 343 278 s s

314. Table 8F: HCBS Population Ages 18-64 Without Intellectual/Developmental Disabilities or Serious Mental Illness | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8f.html
     February 01, 2023 - 22,643   Min s s s s s   Max 42,799 51,459 68,293 75,000 s Pressure … Ulcer 4,950 5,948 3,051 2,700 4,615   Min 1,710 s s s s   Max 19,029 … 5,672 s s 3,977 6,993   Max 41,783 55,696 50,219 s s 49,115 47,727 Pressure … Ulcer 7,200 3,327 4,903 s s 4,833 5,101   Min 2,944 1,030 2,139 s s

315. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
     September 01, 2017 - ulcer, and two medical conditions (cellulitis and hypertension) would trigger Rule 2. … Presence of stage 2 or greater pressure ulcer. … If there is a pressure ulcer stage 2, 3, 4, or unstageable recorded as present within 7 days of the report … clinicians can use the report to track patterns, follow up on areas of decline, and monitor progress of new prevention … clinicians can use the report to track patterns, follow up on areas of decline, and monitor progress of new prevention

316. Update to the "Guidelines for Ensuring the Quality of Information Disseminated to the Public" | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/ahrq-info-quality-gdlns-update.html
     June 01, 2018 - that give easy-to-understand guidance on how to implement quality improvements, such as Preventing Pressure … Ulcers in Hospitals: A Toolkit for Improving the Quality of Care and the AHRQ Health Literacy Universal

317. On-Time Preventable Hospital and Emergency Department Visits (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
     November 30, 2013 - • 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 … ulcer. • Fall risk or previous fall in last 90 days. • Late-loss ADL score ≥12. • Cognitive impairment … ulcer, and two medical conditions, cellulitis and hypertension, would trigger Rule 2. 3. … teams can use the report to track patterns, follow up on areas of decline, and monitor progress of new prevention

318. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhosp-reports-slides.pptx
     November 30, 2013 - ulcer Peripheral vascular disease Respiratory, other nonpneumonia Renal disease Seizure Sepsis/urosepsis … showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure … ulcer, and two medical conditions: cellulitis and hypertension Rules for Determining High Risk Rule … Ulcer Fall Risk Late-Loss ADL Score ≥12 Cognitive Impairment Medical Conditions** High-Risk Medications … rate) Enables clinicians to track patterns, follow up on areas of decline, and monitor progress of new prevention

319. Preventablehospitalandedvisits-Implmatl (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/preventablehospitalandedvisits-implmatl.pdf
     June 03, 2025 - Agency for Healthcare Research and Quality Safety Program for Nursing Homes: On-Time Prevention AHRQ … status   Oxygen dependency   Confusion/mental status change   Any full thickness wound (e.g., pressure … ulcers [Stage II or greater], surgical wound, stasis ulcer)   Polypharmacy (15 or more medications … Chronic pressure ulcers Yes  No  L. Recurrent UTI Yes  No  M. Anemia Yes  No  N. … Section 2: Preventable Hospital Transfer and ED Visits - Prevention Plan For residents at risk:

320. Appendix F. CAUTI Prevention in Long-Term Care: Frequently Asked Questions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.html
     March 01, 2017 - CAUTI Prevention in Long-Term Care: Frequently Asked Questions AHRQ Safety Program … CAUTI Prevention What are the clinical indications for a urinary catheter? … Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral wounds … Centers for Disease Control and Prevention; January 2016. … Guideline for prevention of catheter-associated urinary tract infections 2009.