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421. Table 11: Outcome Indicators by Use of Selected Home and Community-Based Services Medicaid State Plan Services, 2005 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab11.html
     February 01, 2023 - Overall Yes 14,177 28,212 18,788 9,372 No 19,380 19,211 19,521 20,716 Pressure … Ulcer Yes 2,730 11,421 3,150 1,840 No 3,506 3,461 3,696 3,731 Injurious … Composite: ACSC Overall 50,783 40,549 9,972 20,001 18,997 10,923 20,108 19,218 Pressure … Ulcer 12,696 8,204 883 4,475 3,415 1,644 3,729 3,459 Injurious Falls 469

422. Table 19E: SMI Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19e.html
     March 01, 2023 - 6,924 7,208 Composite: ACSC Overall 20,218 17,976 20,084 17,046 19,215 17,075 Pressure … Ulcer 3,124 2,492 3,084 2,232 2,819 2,301 Injurious Falls 297 218 268 212 … 6,471 8,020 7,037 6,881 Composite: ACSC Overall 17,757 20,393 19,476 16,171 Pressure … Ulcer 2,658 2,731 2,846 2,191 Injurious Falls 239 247 236 260 Notes

423. Table 19D: I/DD Subpopulation | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19d.html
     March 01, 2023 - 3,685 2,830 Composite: ACSC Overall 6,401 5,144 6,083 4,903 6,049 4,408 Pressure … Ulcer 1,887 1,225 1,703 1,115 1,573 1,084 Injurious Falls 88 67 77 69 79 … 3,503 3,242 3,720 2,668 Composite: ACSC Overall 5,768 5,111 6,087 4,163 Pressure … Ulcer 1,543 1,223 1,589 999 Injurious Falls 77 67 77 63 Notes:  

424. Table 19G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19g.html
     March 01, 2023 - 12,136 Composite: ACSC Overall 32,463 23,973 25,306 28,599 25,757 29,466 Pressure … Ulcer 4,845 3,916 4,034 4,473 4,279 3,822 Injurious Falls 694 450 520 525 … 12,380 10,227 12,540 Composite: ACSC Overall 24,470 31,390 25,983 29,126 Pressure … Ulcer 4,169 4,242 4,328 3,449 Injurious Falls 498 580 497 653 Notes

425. Table 19C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19c.html
     March 01, 2023 - 4,435 3,912 Composite: ACSC Overall 14,847 12,685 13,750 12,591 14,039 10,413 Pressure … Ulcer 3,144 1,922 2,311 2,203 2,306 2,125 Injurious Falls 114 46 72 55 58 … 4,284 4,429 4,470 3,725 Composite: ACSC Overall 13,151 13,631 14,134 9,746 Pressure … Ulcer 2,071 2,713 2,345 1,945 Injurious Falls 68 59 59 92 Notes:  

426. Table 19B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19b.html
     March 01, 2023 - 8,456 8,118 Composite: ACSC Overall 25,741 19,330 21,845 20,450 21,888 19,402 Pressure … Ulcer 4,659 3,573 4,127 3,570 4,133 3,186 Injurious Falls 476 335 399 346 … 8,162 8,798 8,469 8,012 Composite: ACSC Overall 20,856 22,154 22,042 18,402 Pressure … Ulcer 4,014 3,688 4,171 2,882 Injurious Falls 384 365 381 366 Notes

427. Table 19A: National HCBS Population | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19.html
     March 01, 2023 - 7,387 7,164 Composite: ACSC Overall 23,095 17,584 19,743 18,467 19,802 17,363 Pressure … Ulcer 4,291 3,139 3,655 3,225 3,647 2,945 Injurious Falls 388 259 314 272 … 7,138 7,741 7,427 6,977 Composite: ACSC Overall 18,821 20,092 19,980 16,312 Pressure … Ulcer 3,501 3,452 3,695 2,655 Injurious Falls 301 291 297 299 Notes

428. Table 19F: HCBS Population Ages 18-64 Without I/DD or SMI | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19f.html
     March 01, 2023 - 5,990 6,632 Composite: ACSC Overall 23,094 19,763 20,681 21,282 21,204 19,420 Pressure … Ulcer 6,082 4,303 4,919 4,872 4,765 5,535 Injurious Falls 173 119 141 130 … 5,861 6,673 6,037 6,455 Composite: ACSC Overall 20,343 22,153 21,427 18,076 Pressure … Ulcer 4,499 5,846 4,870 5,072 Injurious Falls 140 131 131 168 Notes

429. 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/impmaterials.html
     June 01, 2017 - Section 1: Screening for Hospital Transfer Risk Section 2: Preventable Hospital and ED Visits - Prevention … |___| Confusion/mental status change |___| |___| Any full thickness wound (e.g., pressure … ulcers [Stage II or greater], surgical wound, stasis ulcer) |___| |___| Polypharmacy (15 or … Chronic pressure ulcers Yes |___| No |___| L. … Meeting Hospital/ED Transfer Prevention Discussed (Yes/No) Meeting Chair/Leader Name and Discipline

430. Missed Nursing Care | PSNet
     psnet.ahrq.gov/primer/missed-nursing-care
     September 15, 2024 - include delayed or omitted medications or treatments; complications such as atelectasis, deconditioning, pressure … ulcers, falls, ventilator-associated pneumonia, or other nosocomial infections; increased length of … Statistically significant impacts were demonstrated on medication errors, patient falls, nosocomial infections, pressure … ulcers, mortality, and patient satisfaction. … Prevention The most consistent predictors of missed nursing care are staffing levels , work environment

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45511/psn-pdf
     July 21, 2017 - Investigators compared a global measure of safety, which included pressure ulcers, venous thromboembolism … preventability-hospital-acquired-venous-thromboembolism https://psnet.ahrq.gov/primer/health-care-associated-infections https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial

432. AHRQ-Funded Patient Safety Project Highlights (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
     August 01, 2025 - Ulcer Prevention in Nursing Homes 2015–2018 $1,783,070 Purpose: 1) Disseminate the On-Time Pressure … effective pressure ulcer prevention practices. … Key Findings/Impact: A final report was not available; however, the Preventing Pressure Ulcers in Hospitals … : Implement and evaluate the effectiveness of a pressure ulcer module, “On-Time Quality Improvement … rates, in reducing the rate of pressure ulcers among nursing home residents.

433. IQI, PSI, AND PDI RATES GENERATED BY THE AHRQ WINDOWS QI SOFTWARE (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
     March 01, 2016 - Ulcer Rate 0 0 - 0.00013297 PDI3 PDI #3 Retained Surgical Item/Unretrieved Device Fragment Count 0 … Count 0 - - - PSI2 PSI #2 Death Rate in Low-Mortality DRGs 8 132 0.06060606 0.00028197 PSI3 PSI #3 Pressure … Ulcer Rate 0 47 0 0.00040548 PSI4 PSI #4 DeathRateSurgInpatientswSeriousTreatableComplications 0 0 … PQI92 PQI #92 Prevention Quality Chronic Composite 795 0.00949090839 PSI21 PSI #21 Retained Surgical … Ulcer Rate 0 47 0 0.000832 0 0.000405 0 0.000379 PSI #4 Death Rate among Surgical Inpatients with

434. The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events. | PSNet
     psnet.ahrq.gov/issue/design-safe-or-sorry-study-cluster-randomised-trial-development-and-testing-evidence-based
     May 22, 2013 - 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 . … July 16, 2013 Centers for Disease Control and Prevention Guideline for the Prevention

435. Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool. | PSNet
     psnet.ahrq.gov/issue/exploring-nursing-sensitive-events-home-healthcare-national-multicenter-cohort-study-using
     August 05, 2020 - December 1, 2021 View More Related Resources The challenge of risk prevention … room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure … ulcers or medication errors?

436. Adverse Events. | PSNet
     psnet.ahrq.gov/issue/adverse-events
     October 28, 2020 - June 29, 2016 National Action Plan for Adverse Drug Event Prevention. … Quality and Safety Professionals Patients Medication Errors/Preventable Adverse Drug Events Pressure … Ulcers Surgical Complications View More

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33734/psn-pdf
     August 01, 2012 - ulcer or were put in physical restraints. … We looked at the outcomes on falls, pressure ulcers, and restraint use. … We didn't find it for pressure ulcers. … ulcers. … But they are mainly medical-based outcomes or process- based outcomes like pressure ulcers, use of restraints

438. References | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/pfp/haccost2017-ref.html
     May 01, 2023 - Office of Disease Prevention and Health Promotion. … Office of Disease Prevention and Health Promotion. National Action Plan for ADE prevention. … Costs of venous thromboembolism, catheter-associated urinary tract infection, and pressure ulcer. … Pressure ulcers in the United States' inpatient population from 2008 to 2012: results of a retrospective … Marginal hospital cost of surgery-related hospital-acquired pressure ulcers.

439. No More Cauti Preventing Cauti Transcript (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/No_More_CAUTI_Preventing_CAUTI_transcript.docx
     May 05, 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.

440. Addressing Questions Asked by Staff: Chlorhexidine for Bathing (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-chg-bathing.pdf
     March 01, 2022 - Do not wipe the CHG off as this will reduce its infection prevention abilities. … Be especially thorough if there are any nearby wounds, pressure ulcers, or breaks in the skin. … Using the CHG cloths on superficial wounds/stage 1 and 2 decubitus ulcers How should we dispose of