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301. Declines in Hospital-Acquired Conditions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf
     January 01, 2019 - Clostridioides difficile Infections -37% Falls -5% Obstetric Adverse Events -5% Pressure … Ulcers 6% Surgical Site Infections 0% Ventilator- Associated Pneumonias -13% Venous

302. 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-

303. 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

304. 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.

305. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
     April 01, 2013 - What is your fall rate or your pressure ulcer rate or whatever? … Let’s think about how you can eliminate hospital-acquired Stage 3 and 4 pressure ulcers. … We want to eliminate preventable Stage 3 and 4 pressure ulcers. … Standardize the pressure ulcer risk assessment. … Your CUSP piece of that, for instance with pressure ulcers under daily goals, when you’re looking at

306. 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

307. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/hac-rates_2019.html
     July 01, 2020 - Pressure ulcers: 6% increase. Surgical site infections: 8% increase.

308. 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

309. NPSD Chartbooks | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/chartbook/index.html
     February 01, 2025 - falls, devices and medical/surgical supply, medication and other substances, perinatal incidents, and pressure … ulcers. … Patient Safety Concerns, which introduces an examination of trends over time and new data: near miss prevention

310. 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

311. Hospitals and Health Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/index.html
     February 01, 2025 - Improving Patient Safety Systems for Patients with Limited English Proficiency NICU Toolkit Preventing Pressure … Ulcers in Hospitals QI Toolkit for Hospitals RED (Re-Engineered Discharge) Toolkit Universal ICU Decolonization

312. 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*

313. 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*

314. 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

315. 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.

316. 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.

317. Resources and Tools on Patient and Healthcare Workforce Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/index.html
     March 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 Interested in

318. 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

319. 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

320. 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