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461. Using Health IT: Eight Quality Improvement Stories (pdf file)
     digital.ahrq.gov/sites/default/files/docs/page/EightSuccessStories_092810.pdf
     September 01, 2010 - Program Nursing Home Health IT Reduces Pressure Ulcers and Increases Staff ’s Job Satisfaction 2 … On-Time reduced the percentage of residents with pressure ulcers and led to closer bedside monitoring … The percentage of residents with high-risk pressure ulcers decreased from 10.8 (in Q1, 2005) to 7.1 … Preventing pressure ulcers: a systematic review. JAMA 2006 Aug 23;296(8):974-84. Takahashi PY. … Pressure ulcers and prognosis: candid conversations about healing and death.

462. Introduction to the Quality Indicators Best Practices Tool (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
     June 02, 2025 - Best practices forms exist for the following 14 PSIs: • PSI 03 Pressure Ulcer Rate • PSI 05 Retained … 03 Neonatal Blood Stream Infection Rate • PDI 01 Accidental Puncture or Laceration Rate • PDI 02 Pressure … Ulcer Rate • PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count • PDI 05 Iatrogenic

463. Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries. | PSNet
     psnet.ahrq.gov/issue/implementing-electronic-root-cause-analysis-reporting-system-decrease-hospital-acquired
     December 22, 2021 - See More About The Topic Hospitals Quality and Safety Professionals Nurse Care Pressure … Ulcers Latent Errors View More

464. Disposition of Comments Report for Chronic Venous Ulcers: A Comparative Effectiveness Review of Treatment Modalities (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/related_files/venous-ulcers-treatment_disposition-comments.pdf
     January 27, 2014 - We would suggest this be reconsidered, especially in light of the role of biofilms in the prevention

465. Detection of adverse events in an acute geriatric hospital over a 6-year period using the Global Trigger Tool. | PSNet
     psnet.ahrq.gov/issue/detection-adverse-events-acute-geriatric-hospital-over-6-year-period-using-global-trigger
     March 09, 2022 - attribute improvements to systems strategies, including checklists , safety culture surveys, and prevention … of pressure ulcers and infections . … April 7, 2021 Evaluation of clinical practice guidelines on fall prevention and management

466. Patients Safer as Hospital-Acquired Conditions Decline (Data Graphic) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-interim-data-graphic-2014.pdf
     January 01, 2014 - hospital-acquired conditions (HACs) such as adverse drug events, healthcare-associated infections, and pressure … ulcers have been prevented in hospital patients.

467. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
     April 01, 2013 - What is your fall rate or your pressure ulcer rate or whatever? … Let’s think about how you can eliminate hospital-acquired Stage 3 and 4 pressure ulcers. … We want to eliminate preventable Stage 3 and 4 pressure ulcers. … Standardize the pressure ulcer risk assessment. … Your CUSP piece of that, for instance with pressure ulcers under daily goals, when you’re looking at

468. Table A: Indicator Rates for the HCBS and Full Medicaid Populations (Rates of Admission per 100,000 Persons) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/oirtab.html
     December 01, 2012 - Composite: ACSC Acute Conditions 6,913 2,846 Composite: ACSC Overall 17,971 7,139 Pressure … Ulcer 3,067 1,136 Injurious Falls 287 105 Source: Schultz, et al., 2012 (see

469. The impact of hospital-acquired conditions on Medicare program payments. | PSNet
     psnet.ahrq.gov/issue/impact-hospital-acquired-conditions-medicare-program-payments
     November 18, 2016 - 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

470. Declines in Hospital-Acquired Conditions | Agency for Healthcare Research and Quality
     www.ahrq.gov/data/infographics/hac-rates_2019.html
     July 01, 2020 - Pressure ulcers: 6% increase. Surgical site infections: 8% increase.

471. Patient safety: moving the bar in prison health care standards. | PSNet
     psnet.ahrq.gov/issue/patient-safety-moving-bar-prison-health-care-standards
     August 28, 2024 - July 29, 2020 Evaluation of clinical practice guidelines on fall prevention and management … January 12, 2022 Are evidence-based practices associated with effective prevention of … hospital-acquired pressure ulcers in US academic medical centers?

472. NPSD Chartbooks | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/chartbook/index.html
     February 01, 2025 - falls, devices and medical/surgical supply, medication and other substances, perinatal incidents, and pressure … ulcers. … Patient Safety Concerns, which introduces an examination of trends over time and new data: near miss prevention

473. 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/ereports.html
     September 01, 2017 - Current clinical conditions contributing to transfer risk: use of oxygen, catheter or ostomy, any pressure … ulcer other than stage I, fall risk, late-loss activities of daily living (ADL) score greater than or … Presence of stage II or greater pressure ulcer. Fall risk or previous fall in last 90 days. … ulcer, and two medical conditions, cellulitis and hypertension, would trigger Rule 2. … teams can use the report to track patterns, follow up on areas of decline, and monitor progress of new prevention

474. Kenneth W. Kizer, MD, MPH: health care quality evangelist. | PSNet
     psnet.ahrq.gov/issue/kenneth-w-kizer-md-mph-health-care-quality-evangelist
     July 28, 2014 - Conversation With… Christine Cassel, MD June 1, 2015 Preventing in-facility pressure … ulcers as a patient safety strategy: a systematic review. … March 20, 2013 Inpatient fall prevention programs as a patient safety strategy: a systematic

475. Maximizing smart pump technology to enhance patient safety. | PSNet
     psnet.ahrq.gov/issue/maximizing-smart-pump-technology-enhance-patient-safety
     April 25, 2018 - July 13, 2022 Are evidence-based practices associated with effective prevention of hospital-acquired … pressure ulcers in US academic medical centers?

476. The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. | PSNet
     psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
     October 09, 2024 - October 9, 2024 Are evidence-based practices associated with effective prevention of … hospital-acquired pressure ulcers in US academic medical centers? … December 21, 2017 Complexity bias in the prevention of iatrogenic injury: why specific … Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention … April 22, 2020 Global Guidelines on the Prevention of Surgical Site Infection.

477. Hospitals and Health Systems | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/index.html
     February 01, 2025 - Improving Patient Safety Systems for Patients with Limited English Proficiency NICU Toolkit Preventing Pressure … Ulcers in Hospitals QI Toolkit for Hospitals RED (Re-Engineered Discharge) Toolkit Universal ICU Decolonization

478. AHRQ Quality Indicators Fact Sheet (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a1a_pdi_pdifactsheet.pdf
     October 01, 2015 - Each PDI in the composite is amenable to prevention through system-level related structures and processes … Infection Rate 25.18 0478 2013 PDI 01 Accidental Puncture or Laceration Rate 0.46 0344 2012 PDI 02 Pressure … Ulcer Rate 0.27 0337 2015 PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count N/A*

479. Fact Sheet on Pediatric Quality Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1c_combo_pdifactsheet.pdf
     October 01, 2015 - Each PDI in the composite is amenable to prevention through system-level related structures and processes … Infection Rate 25.18 0478 2013 PDI 01 Accidental Puncture or Laceration Rate 0.46 0344 2012 PDI 02 Pressure … Ulcer Rate 0.27 0337 2015 PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count N/A*

480. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40390/psn-pdf
     February 03, 2015 - billion, largely attributable to post-surgical complications, health care–associated infections, and pressure … ulcers.