-
www.ahrq.gov/data/infographics/hac-rates_2019.html
July 01, 2020 - Pressure ulcers: 6% increase. Surgical site infections: 8% increase.
-
www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac_rates_2019.pdf
January 01, 2019 - Clostridioides
difficile
Infections
-37%
Falls
-5%
Obstetric
Adverse
Events
-5%
Pressure … Ulcers
6%
Surgical
Site
Infections
0%
Ventilator-
Associated
Pneumonias
-13%
Venous
-
www.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
January 01, 2019 - CLABSI+
-6%
Clostridioides
difficile
Infections
-37%
Falls
-5%
Obstetric
Adverse
Events
-3%
Pressure … Ulcers
Surgical
Site
Infections
Ventilator-
Associated
Pneumonias
-13%
Venous
Thrombo-
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/index.html
November 01, 2021 - Injury
Long-Term Care Facilities
Multiple Chronic Conditions
Omissions of Care in Nursing Homes
Pressure … Ulcers
Quality of Life
TeamSTEPPS
Nursing Home Antimicrobial Stewardship Guide
-
www.ahrq.gov/action-alliance/resources/index.html
March 01, 2025 - Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure … Ulcers Readmissions Sepsis Surgical Safety Transitions in Care Venous Thromboembolism Interested in
-
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
-
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.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c3_combo_staffpresentation.pptx
January 01, 2006 - , with specific information tailored to the example indicator:
The indicator that we have chosen, Pressure … Ulcers (PSI 03), is important to our patients because improvement on this indicator may reduce:
Sepsis … In this example, we will examine the rates of Pressure Ulcers (PSI 03) for this particular hospital performed … Rates of Neonatal Blood Stream Infection Rate (NQI 3)
Per 1,000 Cases
Examining Observed Rates of Pressure … Ulcers (PSI 03)
Observed Rate 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 4.9136800000000001E
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
June 01, 2014 - Trauma in
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 Site
Infection
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
June 02, 2025 - 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
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17c.html
February 01, 2023 - 5,049
3,932
Composite: ACSC Overall
15,281
10,642
14,988
12,306
15,447
12,117
Pressure … Ulcer
2,935
1,376
2,649
2,045
3,140
1,790
Injurious Falls
76
51
101
45
98 … 4,416
4,102
5,111
4,002
Composite: ACSC Overall
13,885
11,778
15,231
12,519
Pressure … Ulcer
2,200
2,447
3,298
1,833
Injurious Falls
66
63
119
44
Notes:
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17b.html
February 01, 2023 - 10,530
7,005
Composite: ACSC Overall
24,760
16,334
23,622
19,729
26,330
18,086
Pressure … Ulcer
4,583
2,937
4,303
3,638
4,774
3,353
Injurious Falls
397
350
396
366 … 8,314
8,522
10,408
7,479
Composite: ACSC Overall
21,408
21,005
25,803
19,316
Pressure … Ulcer
4,098
3,440
4,727
3,530
Injurious Falls
384
363
466
342
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17d.html
February 01, 2023 - 3,815
3,120
Composite: ACSC Overall
6,079
4,558
5,662
5,312
6,245
5,000
Pressure … Ulcer
1,619
1,071
1,367
1,440
1,749
1,185
Injurious Falls
81
60
90
55
92 … 3,481
3,208
3,831
3,228
Composite: ACSC Overall
5,719
5,011
6,399
5,136
Pressure … Ulcer
1,498
1,217
1,890
1,213
Injurious Falls
80
57
88
68
Notes:
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17.html
February 01, 2023 - 9,215
6,184
Composite: ACSC Overall
22,374
14,832
21,534
17,751
23,720
16,492
Pressure … Ulcer
4,168
2,525
3,903
3,214
4,382
2,935
Injurious Falls
316
271
324
280 … 7,298
7,429
9,114
6,570
Composite: ACSC Overall
19,447
18,724
23,221
17,538
Pressure … Ulcer
3,603
3,194
4,378
3,086
Injurious Falls
301
289
382
264
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17g.html
February 01, 2023 - 13,941
8,615
Composite: ACSC Overall
31,820
19,437
32,312
23,141
34,235
21,902
Pressure … Ulcer
5,156
2,917
5,215
3,604
5,195
3,597
Injurious Falls
568
461
588
484 … 10,221
11,658
13,626
9,337
Composite: ACSC Overall
25,759
28,549
32,778
23,897
Pressure … Ulcer
4,379
3,646
4,962
3,857
Injurious Falls
504
573
687
457
Notes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
October 01, 2015 - ulcer)
• Denominator = population at risk (e.g., hospitalized
patients)
• Observed rate = numerator … ulcer in any secondary diagnosis field
among cases meeting the inclusion and exclusion
rules for the … • Several exclusions (e.g., length of stay <5 days,
principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02)
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)�
How can the AHRQ PDIs be used in�quality assessment?
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17f.html
February 01, 2023 - 7,139
5,429
Composite: ACSC Overall
23,940
16,507
25,790
18,529
23,803
18,978
Pressure … Ulcer
5,875
3,508
6,077
4,338
6,250
4,022
Injurious Falls
147
123
175
119 … 6,119
6,072
7,171
5,539
Composite: ACSC Overall
21,607
19,235
23,468
19,546
Pressure … Ulcer
4,785
5,171
6,257
4,181
Injurious Falls
145
120
171
121
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17e.html
February 01, 2023 - 8,838
5,914
Composite: ACSC Overall
20,734
15,368
19,563
17,756
23,009
16,087
Pressure … Ulcer
2,980
2,213
2,877
2,492
3,415
2,252
Injurious Falls
253
224
263
220 … 6,956
7,098
7,925
6,580
Composite: ACSC Overall
19,175
17,427
20,509
17,826
Pressure … Ulcer
2,820
2,361
3,195
2,436
Injurious Falls
251
221
300
217
Notes
-
www.ahrq.gov/research/findings/final-reports/index.html?page=8
January 01, 2024 - Publication Date: March 2015
Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Ulcers ( application/pdf 844258 ) Principal Investigators: Stifter, et al. … Coordination, Health Information Technology and Health Information Exchange, Human and Environmental Factors, Pressure … Ulcers Publication Date: December 2014
The Value of Hospital-Related Patient-Safety Interventions
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab10.html
February 01, 2023 - Composite: ACSC Overall
Yes
22,422
20,395
25,160
No
18,138
19,018
17,666
Pressure … Ulcer
Yes
5,006
4,208
4,833
No
2,960
3,348
3,127
Injurious Falls
Yes
307 … 7,607
Composite: ACSC Overall
20,384
19,444
14,877
19,094
19,184
20,443
Pressure … Ulcer
4,195
4,249
2,476
3,395
3,286
3,764
Injurious Falls
388
259
218