-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15.html
February 01, 2023 - Ulcer
3,341
3,555
3,254
3,604
Injurious Falls
429
263
406
260
Dually Eligible … Ulcer
3,678
4,011
3,589
4,072
Injurious Falls
520
339
493
336
Medicaid-Only … Ulcer
4,049
4,237
4,031
4,256
Injurious Falls
778
456
729
451
HCBS … Ulcer
3,678
4,011
3,589
4,072
Injurious Falls
520
339
493
336
Medicaid-Only … Ulcer
4,049
4,237
4,031
4,256
Injurious Falls
778
456
729
451
Notes
-
www.ahrq.gov/practiceimprovement/index.html
June 01, 2025 - Improving Quality Tools Toolkit Training Prevention Task Force Application to help primary care clinicians … On-Time Pressure Ulcer Prevention Tools to assist nursing homes that have electronic medical record systems
-
psnet.ahrq.gov/node/43125/psn-pdf
December 12, 2014 - authors attribute improvements to systems strategies,
including checklists, safety culture surveys, and prevention … of pressure ulcers and infections. … checklists
https://psnet.ahrq.gov/primer/culture-safety
https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s)
present … Ulcers
( (“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “Bedsore” [tiab] OR “Bed Sores” [tiab … ] OR “Decubitus
Ulcer” [tiab] OR “Pressure Sore” [MeSH] OR “Pressure Sore” [tiab] OR “Suspected Deep … Tissue Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ulcer
All hospitalized patients
who are at risk to have
pressure ulcer
0.018c 2.42–5.06 3.26
-
www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s)
present … Ulcers
( (“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “Bedsore” [tiab] OR “Bed Sores” [tiab … ] OR “Decubitus
Ulcer” [tiab] OR “Pressure Sore” [MeSH] OR “Pressure Sore” [tiab] OR “Suspected Deep … Tissue Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ulcer
All hospitalized patients
who are at risk to have
pressure ulcer
0.018c 2.42–5.06 3.26
-
psnet.ahrq.gov/issue/dissecting-leapfrog-how-well-do-leapfrog-safe-practices-scores-correlate-hospital-compare
September 19, 2012 - with Hospital Compare data on hospital-acquired conditions like health care–associated infections , pressure … ulcers , or falls . … October 29, 2017
Success in hospital-acquired pressure ulcer prevention: a tale in two … September 23, 2020
Comparing catheter-associated urinary tract infection prevention programs
-
www.ahrq.gov/topics/injuries-and-wounds.html
Topic: Injuries and Wounds
AHRQ wound research centers on pressure ulcers. … AHRQ’s Safety Program for Nursing Homes: On-Time Prevention
We Must Not Underestimate the Impacts
-
www.ahrq.gov/hai/pfp/hacrate2011-12.html
January 01, 2018 - Centers for Disease Control and Prevention. … Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
82,000
2.51
77,000
2.36
Pressure … Ulcer
MPSMS
Hospital-Acquired Pressure Ulcers
1,320,000
40.41
1,300,000
39.43
Surgical
-
psnet.ahrq.gov/node/47788/psn-pdf
March 06, 2019 - Medical device-related pressure ulcers: a systematic
review and meta-analysis. … Medical device-related pressure ulcers: A systematic review and
meta-analysis. … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis … Hospital-acquired pressure ulcers are considered never events and represent a significant source of … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis
-
psnet.ahrq.gov/issue/cracking-code-quality-interrelationships-culture-nurse-demographics-advocacy-and-patient
December 01, 2011 - surveyed about perceptions on safety culture , patient advocacy, patient experience, and fall and pressure … ulcer rates. … June 16, 2021
Fall prevention implementation strategies in use at 60 United States hospitals … About The Topic
Hospitals
Operating Room
Nurse Managers
Medical/Surgical Nursing
Pressure … Ulcers
View More
-
psnet.ahrq.gov/node/44098/psn-pdf
April 29, 2015 - ulcers: a systematic review and documentary
analysis. … ulcers: a systematic review and documentary analysis. … ulcers. … In hospital and long-term care settings, pressure ulcers are considered
preventable complications, but … https://psnet.ahrq.gov/primer/root-cause-analysis
https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
-
psnet.ahrq.gov/issue/front-line-defense-role-nurses-preventing-sentinel-events-third-edition
November 27, 2018 - provides strategies for nurses to identify and help prevent sentinel events, with each chapter discussing prevention … December 15, 2017
Organisational strategies to implement hospital pressure ulcer prevention … December 16, 2015
ANA CAUTI Prevention Tool. … November 16, 2015
Infection Prevention.
-
psnet.ahrq.gov/node/42083/psn-pdf
March 13, 2013 - Progress in patient safety improvement has been hindered by a lack of high-quality research on error
prevention … health care–associated infections and surgical
complications, bundled interventions to reduce falls and pressure … ulcers, and interventions to decrease
medication errors and improve hand hygiene—are all considered … surgical-safety-checklist-reduce-morbidity-and-mortality-global-population
https://psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review … https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-wound-cleaning.pdf
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/ … Do not
wipe off the CHG as this will reduce its infection prevention abilities.
AHRQ Pub.
-
psnet.ahrq.gov/issue/mindful-path-nursing-accuracy-quasi-experimental-study-minimizing-medication-administration
March 03, 2019 - Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention … August 26, 2020
Organisational strategies to implement hospital pressure ulcer prevention … December 30, 2014
Detection and prevention of medication errors using real-time bedside
-
psnet.ahrq.gov/node/46027/psn-pdf
July 02, 2019 - with Hospital Compare data on hospital-
acquired conditions like health care–associated infections, pressure … ulcers, or falls. … https://psnet.ahrq.gov/primer/health-care-associated-infections
https://psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero … https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
-
psnet.ahrq.gov/node/43711/psn-pdf
November 26, 2014 - evaluated costs related to the index hospitalization and 90 days following discharge of six
HACs—severe pressure … ulcers, fractures, catheter-associated urinary tract infections, venous catheter-
related infections … Severe pressure
ulcers and orthopedic surgical site infections resulted in an average increase in payments … psnet.ahrq.gov/primer/health-care-associated-infections
https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review … https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
-
psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - View More
Related Resources
Organisational strategies to implement hospital pressure … ulcer prevention programmes: findings from a national survey. … September 22, 2017
ANA CAUTI Prevention Tool. … November 16, 2015
Fall prevention in hospitals: an integrative review.
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - ulcer
o Most advanced stage of pressure ulcer
o Stage on admission
o Admission skin inspection documented … o Pressure ulcer prevention intervention in place
o Secondary patient morbidity
• Surgery or anesthesia … Some of these explanatory statements were
related to fall and pressure ulcer events, while others were … Pressure Ulcer Event Very busy environment due to COVID-19 crisis and less time and
attention paid to … Pressure Ulcer Event
Patient is critically ill, intubated, COVID-19 positive, in multisystem organ
-
psnet.ahrq.gov/node/73350/psn-pdf
June 02, 2021 - learning-during-crisis-impact-covid-19-hospital-acquired-pressure-injury-incidence
https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program … https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review