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261. Avoidable sepsis infections send thousands of seniors to gruesome deaths. | PSNet
     psnet.ahrq.gov/issue/avoidable-sepsis-infections-send-thousands-seniors-gruesome-deaths
     March 27, 2019 - 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-term … March 24, 2021 Infection prevention in long-term care: re-evaluating the system using

262. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/small_hospitals-slides/Small-and-Rural-Critical-Access-Hospitals-July-19-2011-508.ppt
     January 01, 2011 - Flook, RN, MPH, CIC Director, Workforce Development & Infection Prevention Lorna Martin, RN Patient … ulcers The CUSP/Improvement Intervention Alt text CUSP 1. … Provide feedback, investigate each case Eliminate Stage 3, 4 Pressure Ulcers 1. … Standardized pressure ulcer risk assessment 3. … Flook, RN, MPH,CIC Director, Workforce Development/Infection Prevention 770-249-4518 dflook@gha.org.

263. Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/topics/prevention.html
     Topic: Prevention Preventing disease and helping patients maximize health and function over the life … AHRQ’s Prevention/Care Management Portfolio works to improve the delivery of primary care services to … Achievements in Prevention AHRQ Highlights Urgent Need for Research to Improve Delivery of Preventive … Services to People with Disabilities AHRQ Research Findings Support Effort to Reduce Pressure … Ulcers in Virginia Celebrating the 40th Anniversary of the U.S.

264. Interim Update on 2013 Annual Hospital-Acquired Condition Rate (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014finalhacreport-cx.pdf
     December 01, 2016 - 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 … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC.

265. Final Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
     December 01, 2016 - 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 … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC.

266. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44525/psn-pdf
     October 21, 2015 - Wound-care teams for preventing and treating pressure ulcers. … Wound-care teams for preventing and treating pressure ulcers. … https://psnet.ahrq.gov/issue/wound-care-teams-preventing-and-treating-pressure-ulcers Pressure ulcers … https://psnet.ahrq.gov/issue/wound-care-teams-preventing-and-treating-pressure-ulcers https://psnet.ahrq.gov … /issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review https://psnet.ahrq.gov

267. Connecticut Hospital Reduces Pressure Injuries Using AHRQ Toolkit | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/case-studies/201802.html
     August 01, 2018 - Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care was central to the … hospital’s effort to prevent an estimated 114 pressure ulcers and avoid nearly $2 million in excess hospital … Saint Francis, pressure injuries identified as Stage 2 (characterized by partial loss of skin at the bedsore … Saint Francis implemented the toolkit as part of an AHRQ-sponsored Hospital Pressure Ulcer Training Program … Safety, Pressure Ulcers, Quality of Care Geographic Location: Connecticut

268. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications2/files/interimhacrate2014_cx.pdf
     November 19, 2015 - 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 … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 7 2010 baseline data … ulcer, rather than on the incremental cost due to the HAC. 13 Saving Lives and Saving Money: Hospital-Acquired

269. Saving Lives and Saving Money: Hospital-Acquired Conditions Update - Interim Data From National Efforts To Make Care Safer, 2010-2014 (pdf file)
     www.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
     November 19, 2015 - 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 … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 7 2010 baseline data … ulcer, rather than on the incremental cost due to the HAC. 13 Saving Lives and Saving Money: Hospital-Acquired

270. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts To Make Health Care Safer | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2015-interim.html
     December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … The Centers for Disease Control and Prevention (CDC) data for surgical site infections (SSIs) are also … Ulcers MPSMS (2015) Hospital-Acquired Pressure Ulcers 1,190,000 36.3 Surgical Site Infections … ulcer, rather than on the incremental cost due to the HAC. … [7] The AHRQ-developed pressure ulcer toolkit and falls toolkit are online.

271. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37270/psn-pdf
     January 02, 2017 - Preventing pressure ulcers: the goal is zero. January 2, 2017 Duncan KD. … Preventing pressure ulcers: the goal is zero. Jt Comm J Qual Patient Saf. 2007;33(10):605-10. … https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero This article discusses the background … and motivation behind the 5 Million Lives Campaign goal to prevent and eliminate pressure ulcers. … https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero https://psnet.ahrq.gov/issue/5-million-lives-campaign

272. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38625/psn-pdf
     November 19, 2009 - randomised trial on the development and testing of an evidence based inpatient safety program for the prevention … randomised trial on the development and testing of an evidence based inpatient safety program for the prevention … implementation of a patient safety program focused on evidence-based guidelines to reduce the incidence of pressure … ulcers, falls, and urinary tract infections. … making-health-care-safer-critical-analysis-patient-safety-practices https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero

273. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - disinfection [ti] OR wash [ti]))) OR (Accidental Falls [mh] OR (fall* [ti] AND (preventing [ab] OR prevention … [ab] OR reducing [ab] OR reduction [ab] OR aged [mh] OR elderly OR geriatric)) OR Decubitus Ulcer [mh

274. Small and Rural Critical Access Hospitals (Slide Presentation) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals/slides.html
     October 01, 2014 - Flook, RN, MPH, CIC Director, Workforce Development & Infection Prevention Lorna Martin, RN Patient … Walking Through the Process Eliminate Hospital-Acquired Stage 3/4 Pressure Ulcers on the Unit  … ulcers Return to Contents   Slide 13. … Ulcers Comprehensive skin assessment Standardized pressure ulcer risk assessment Care planning … Flook, RN, MPH,CIC Director, Workforce Development/Infection Prevention 770-249-4518 dflook@gha.org

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43524/psn-pdf
     October 29, 2014 - study found that diagnostic codes in administrative data for hospital-related complications such as pressure … ulcers, falls, and adverse drug events accurately reflect the presence of these events in the medical … validating-administrative-data-detection-adverse-events-older-hospitalized-patients https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review … https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial https://psnet.ahrq.gov

276. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - 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 … Ulcers MPSMS (2014) Hospital-Acquired Pressure Ulcers 1,010,000 30.9 Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC. 1 AHRQ Partnership for Patients Web page

277. Patient Safety Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
     June 01, 2022 - Prevention Quality Indicators identify hospital admissions in geographic areas that evidence suggests … The strategies can help prevent harmful events such as medication errors, bed sores, and healthcare-associated … The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … The toolkit draws on literature on best practices in pressure ulcer prevention and includes both validated

278. Outcome Indicators for the HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find4.html
     December 01, 2012 - All but two of the indicators (Pressure Ulcer and Injurious Falls) build on existing AHRQ Prevention … Pressure Ulcer. Injurious Falls.

279. FAQs (Staff): Wound Cleaning (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-wound-cleaning.docx
     March 01, 2022 - CHG in clinical trials with the explicit instructions to clean superficial wounds and stage 1 and 2 decubitus … ulcers. … CHG can be applied to any superficial wound, including stage 1 and 2 decubitus ulcers, friable skin/rashes … Do not wipe off the CHG as this will reduce its infection prevention abilities. AHRQ Pub.

280. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
     September 01, 2011 - Unfortunately, likely secondary to an infection of the pressure ulcer, she developed septic shock and … Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. … Reston, VA: National Pressure Ulcer Advisory Panel; 2001. … RN staffing time and outcomes of long-stay nursing home residents: pressure ulcers and other adverse … Organizations can monitor their rates of falls, pressure ulcers, infections, unplanned hospitalizations