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201. Module 2: How To Manage Change (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange.docx
     June 02, 2025 - Ulcer Policies Tool 2E: Assessing Screening for Pressure Ulcer Risk Tool 2F: Assessing Pressure … Ulcer Care Planning Alert the Implementation Team Leader to be ready to discuss and decide who … will oversee administering the Pieper Pressure Ulcer Knowledge Test to staff, and who will be in charge … Ulcer Policies (completed by the Implementation Team Leader) Tool 2E: Assessing Screening for Pressure … Ulcer Risk (completed by the Implementation Team Leader or designee) Tool 2F: Assessing Pressure Ulcer

202. Accelerating Change and Transformation in Organizations and Networks (ACTION) | Digital Healthcare Research
     digital.ahrq.gov/funding-mechanism/accelerating-change-and-transformation-organizations-and-networks-action
     January 01, 2023 - of Implementing Health Information Technology Evaluation of AHRQ's on-time pressure … ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing … Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision … Principal Investigator Hurd, Donna Project Name Evaluation of AHRQ's On-time Pressure … Ulcer Program Provider perceptions of colorectal cancer screening clinical decision

203. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
     June 02, 2025 - ulcer prevention training. … ulcers, pressure ulcers that are not healing appropriately, falls, and preventable hospitalizations … For example:  Pressure Ulcer Prevention has been pilot tested in more than 50 nursing homes across … the country; several studies have shown significant reductions in pressure ulcer incidence rates … when On-Time pressure ulcer prevention reports were integrated into day-to-day workflow

204. Generic Dashboard Data 2024 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
     January 01, 2024 - Ulcer Communication 167 2.2% Pressure Ulcer Data * * Pressure Ulcer Environment 29 0.4% Pressure … 0.3% Pressure Ulcer Staff qualifications 184 2.4% Pressure Ulcer Supervisor/Support * * Pressure … Gen_7 Near Miss Prevention Actions within Event Types Event Type Near Miss Prevention Action Event … * * Pressure Ulcer UNK Female Unknown Harm * * Pressure Ulcer UNK Male Mild Harm 63 75.0% Pressure … Ulcer UNK Male Moderate Harm * * Pressure Ulcer UNK Male No Harm 17 20.2% Pressure Ulcer UNK Male

205. Home and Community-Based Services Quality Indicators: (pdf file)
     qualityindicators.ahrq.gov/Downloads/Resources/Publications/2012/Appendix_1A_Details_of_literature_review.pdf
     January 01, 2012 - Evidence for prevention of pressure ulcers in HCBS populations Prevention of Pressure Ulcer Development … Prevention of Pressure Ulcer Progression • Pressure ulcers in vulnerable populations should be assessed … Pressure Ulcer Pressure Ulcers 23 • One study found that pressure ulcers were associated with … Frequency of Admissions for Pressure Ulcer • Pressure ulcers are associated with an average length … "Support surfaces for pressure ulcer prevention." Cochrane Database Syst Rev(4): CD001735.

206. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47338/psn-pdf
     September 19, 2018 - in nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure … ulcers and sepsis that result in hospital admissions and death. … A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long … avoidable-sepsis-infections-send-thousands-seniors-gruesome-deaths https://psnet.ahrq.gov/issue/rory-staunton-foundation-sepsis-prevention … psnet.ahrq.gov/primer/long-term-care-and-patient-safety https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

207. The Safety and Quality of Long Term Care | PSNet
     psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
     January 01, 2016 - At the hospital, a full examination revealed a very deep pressure ulcer in her sacrum (stage IV full … For example, the rate of pressure ulcers in nursing homes has been shown to range between 2.2% to 23.9% … Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. … Reston, VA: National Pressure Ulcer Advisory Panel; 2001. 6. … RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse

208. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48085/psn-pdf
     June 19, 2019 - The health system sought to prevent pressure ulcers, adverse drug events, falls with injury, health … psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals https://psnet.ahrq.gov/issue/success-hospital-acquired-pressure-ulcer-prevention-tale-two-data-sets … psnet.ahrq.gov/primer/leadership-role-improving-safety https://psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program

209. Wound-care teams for preventing and treating pressure ulcers. | PSNet
     psnet.ahrq.gov/issue/wound-care-teams-preventing-and-treating-pressure-ulcers
     June 05, 2019 - Review Wound-care teams for preventing and treating pressure ulcers. … Wound-care teams for preventing and treating pressure ulcers. … Pressure ulcers are considered a never event for hospitals. … Wound-care teams for preventing and treating pressure ulcers. … April 29, 2015 Preventing in-facility pressure ulcers as a patient safety strategy: a

210. Towards international consensus on patient harm: perspectives on pressure injury policy. | PSNet
     psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-policy
     September 27, 2016 - Pressure ulcers are never events that continue to occur, despite potential repercussions on reimbursement … December 8, 2021 Medical device-related pressure ulcers: a systematic review and meta-analysis … March 6, 2019 Success in hospital-acquired pressure ulcer prevention: a tale in two data … February 3, 2015 Preventing in-facility pressure ulcers as a patient safety strategy: … Ulcers View More

211. Early identification and evaluation of severe pressure injuries. | PSNet
     psnet.ahrq.gov/issue/early-identification-and-evaluation-severe-pressure-injuries
     October 10, 2018 - summarizes recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure … ulcers including recognition of conditional risks and educational strategies . … October 21, 2020 Proactive prevention of maternal death from maternal hemorrhage. … September 14, 2022 Accuracy of pressure ulcer events in US nursing home ratings. … Ulcers View More

212. Describe How a Plan or Provider Can Influence a Quality Measure | Agency for Healthcare Research and Quality
     www.ahrq.gov/talkingquality/translate/labels/describe.html
     January 01, 2023 - Overall, the rate of patients who have pressure ulcers at MGH is low. … We achieve this by focusing on prevention. … They are also supported in their work toward pressure ulcer prevention by their local Clinical Nurse … Bed surface is a key factor in preventing pressure ulcers. … The highest percentage of pressure ulcers occur in our intensive care areas where our patients have complex

213. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
     November 01, 2017 - version of On-Time introduction is for training Facilitators who have not had pressure ulcer prevention … It is more difficult for staff to identify which residents are at risk for a fall or pressure ulcer or … ulcers, pressure ulcers that are not healing appropriately, falls, and preventable hospitalizations. … For example: Pressure Ulcer Prevention has been pilot tested in more than 50 nursing homes across … On-Time pressure ulcer prevention reports were integrated into day-to-day workflow.

214. How To Manage Change
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
     June 02, 2025 - (Tool 2C) Present the assessment of current pressure injury prevention policies and procedures. … Relationships Unit-Based Team Staff on the unit who provide daily care to patients, including skin and pressure … ulcer assessment and care planning Wound Care Team Interdisciplinary group of experts who provide … patient/family Implementation Team Interdisciplinary team charged with designing and implementing pressure … ulcer change project 13 Assess Current Pressure Injury Processes Understand current

215. lessons learned, successes, and barriers for the ‘Real-Time’ and QIO ‘ON-Time’ projects (pdf file)
     digital.ahrq.gov/sites/default/files/docs/resource/Real_Time_and_On_Time_Lessons_Learned_9_6_06.pdf
     June 16, 2021 - NPULS (National Pressure Ulcer Long Term Care Study) research results helped to focus improvement initiative … By taking an overall systems approach, in addition to incorporating National Pressure Ulcer Long-term … Redesigned clinical workflow to incorporate evidence-based best practices for pressure ulcer prevention … In addition, providing data showing the team’s impact on pressure ulcer rates and operational efficiencies … (Note: in the dissemination initiative ‘On-Time Pressure Ulcer Prevention: Partnership with QIOs’ the

216. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49633/psn-pdf
     September 01, 2011 - For example, the rate of pressure ulcers in nursing homes has been shown to range between 2.2% to 23.9% … ulcer risk so that aggressive prevention strategies could have been put in place. … Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. … Reston, VA: National Pressure Ulcer Advisory Panel; 2001. 6. … RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse

217. From Quality Measures to Quality Care: Examples of Quality Improvement at Work | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-measures/21st-century/challenges.html
     June 01, 2018 - Reducing the Incidence of Pressure Ulcers For the hospitalized and home care patient, pressure ulcers … , or bed sores, can be a serious and chronic problem. … , and treatment of pressure ulcers ( Bergstrom, 1992 ; Bergstrom, 1994 ). … The VA viewed pressure ulcer development as an ideal indicator because they are common, required the … The rate of pressure ulcer development dropped from 11.5 percent to zero.

218. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44953/psn-pdf
     March 09, 2016 - Students demonstrated a wide range of accuracy in identifying hazards, with fall risk most likely and pressure … ulcer risk least likely to be identified. … patient-safety-room-horrors-novel-method-assess-medical-students-and-entering-residents https://psnet.ahrq.gov/primer/simulation-training https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial … https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review

219. 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/factraining.html
     September 01, 2017 - ulcer prevention training. … It is more difficult for staff to identify which residents are at risk for a fall or pressure ulcer or … ulcers, pressure ulcers that are not healing appropriately, falls, and preventable hospitalizations. … For example: Pressure Ulcer Prevention has been pilot tested in more than 50 nursing homes across … On-Time pressure ulcer prevention reports were integrated into day-to-day workflow.

220. USA, MA, Cambridge | Digital Healthcare Research
     digital.ahrq.gov/location/usa-ma-cambridge
     January 01, 2023 - Principal Investigator(s) Spranca, Mark Evaluation of AHRQ's On-time Pressure … Ulcer Program Description Lessons from the On-Time Pressure Ulcer program informed the development … of an On-Time Fall Prevention module, which uses documentation data elements, actionable reports, and