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  1. 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 PressureUlcer 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 PressureUlcer 12,696 8,204 883 4,475 3,415 1,644 3,729 3,459 Injurious Falls 469
  2. 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 PressureUlcer 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 PressureUlcer 3,501 3,452 3,695 2,655 Injurious Falls 301 291 297 299 Notes
  3. 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 PressureUlcer 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 PressureUlcer 1,543 1,223 1,589 999 Injurious Falls 77 67 77 63 Notes:  
  4. 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 PressureUlcer 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 PressureUlcer 4,499 5,846 4,870 5,072 Injurious Falls 140 131 131 168 Notes
  5. www.ahrq.gov/patient-safety/reports/engage/appc.html
    March 01, 2017 - ab] OR prevention [ab] OR reducing [ab] OR reduction [ab] OR aged [mh] OR elderly OR geriatric)) OR DecubitusUlcer [mh] OR ((pressure [ti] OR decubitus [ti]) AND ulcer* [ti]) OR decubiti [ti])) AND ((((Randomised
  6. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
    October 01, 2017 - Slide 6: On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer Prevention PressureUlcer Healing Falls Prevention Preventable Hospital and ED Visits Slide 7: Common Elements … Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation.
  7. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facslides.html
    September 01, 2017 - Slide 6: On-Time Reports for  Four Adverse Events Four Reports: Pressure Ulcer Prevention. … Pressure Ulcer Healing. Falls Prevention. Preventable Hospital and ED Visits. … Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation.
  8. www.ahrq.gov/research/publications/ahrq-info-quality-gdlns-update.html
    June 01, 2018 - that give easy-to-understand guidance on how to implement quality improvements, such as Preventing PressureUlcers in Hospitals: A Toolkit for Improving the Quality of Care and the AHRQ Health Literacy Universal
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pptx
    October 01, 2015 - Ulcer Rate PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count PDI 05 Iatrogenic Pneumothorax … ulcer) Denominator = population at risk (e.g., hospitalized patients) Observed rate = numerator/denominator … 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) Tool A.2 Slide ‹#› Pediatric Toolkit for Using the AHRQ Quality
  10. www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-chg-bathing.docx
    March 01, 2022 - 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 the
  11. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
    June 02, 2025 - Care plan addressing every deficit on pressure ulcer risk factor assessment has been developed and is … 46 Next Steps Over the next several weeks, we will meet weekly to refine your Action Plan for the PressureUlcer Prevention Program.
  12. www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2024.xlsx
    January 01, 2024 - 10.5% Surgery or Anesthesia CFER-H V1.1 25,264 9.4% Surgery or Anesthesia CFER-H V1.2 132,724 5.2% PressureUlcer CFER-H V1.1 16,374 6.1% Pressure Ulcer CFER-H V1.2 124,964 4.9% Device or Medical/Surgical Supply
  13. www.ahrq.gov/sites/default/files/2024-05/felix-report.pdf
    January 01, 2024 - Being underweight increased the odds of experiencing a fall, fall with injury, or pressure ulcer but … ulcers/ injuries and UTIs. … Association of overweight and obesity with the prevalence and incidence of pressure ulcers: A systematic … The paradox of obesity in pressure ulcers of critically ill patients. … Obesity and pressure ulcers among nursing home residents. Medical Care. 2013;51(6):478-86. 44.
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxoverview.pptx
    October 01, 2017 - On-Time Overview 5 October 2017 5 On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer … Prevention Pressure Ulcer Healing Falls Prevention Preventable Hospital and ED Visits On-Time Overview … leading clinicians Reports tested in clinical settings for feasibility and ease of use Large decline in pressureulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation October 2017 On-Time Overview
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/ontime-preventablehospitaledvisits-overview.pptx
    May 01, 2017 - May 2017 On-Time Overview 5 5 On-Time Reports for Four Adverse Events Four Reports Pressure Ulcer … Prevention Pressure Ulcer Healing Falls Prevention Preventable Hospital and ED Visits May 2017 On-Time … leading clinicians Reports tested in clinical settings for feasibility and ease of use Large decline in pressureulcer incidence rate seen in Pressure Ulcer Prevention Program Evaluation May 2017 On-Time Overview
  16. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
    April 01, 2022 - strict immobility post-procedure, and urinary incontinence contaminating open (stage 3 or stage 4) pressureulcers. … ulcers and weakness from less walking. … ulcers. … ulcers.
  17. www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-nh_webcast-castle.pdf
    January 01, 2006 - Hospitals ►Moving, Transferring, or Lifting Residents ►Medication errors ►Falls ►Pressure ulcers ►Sanitation
  18. www.ahrq.gov/npsd/data/chartbook/index.html
    February 01, 2025 - falls, devices and medical/surgical supply, medication and other substances, perinatal incidents, and pressureulcers.
  19. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications.pptx
    April 01, 2022 - Closed pressure ulcers: stage I, deep tissue injury No No, unless has chronic ISC needs Yes, if the patient … Open pressure ulcers: stage II Uncertain Yes Yes, if the patient is unable to toilet using other means … , bedpan, bedside commode, bathroom All† Open pressure ulcers: stages III-IV, unstageable Yes Yes,
  20. 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 PressureUlcer Rate • PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count • PDI 05 Iatrogenic

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