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321. 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.

322. 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

323. 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.

324. 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

325. 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

326. 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

327. 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

328. 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

329. 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

330. 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.  

331. 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

332. 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

333. 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

334. 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

335. 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

336. 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

337. 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

338. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/interimhacrate2014.html
     January 01, 2018 - 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 … Prevention of approximately 87,000 deaths in the 2011 to 2014 period as a result of the decline in HACs

339. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
     January 01, 2019 - 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 (13,101 / 47,110; 27.8%) 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

340. 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