-
www.ahrq.gov/hai/cauti-tools/archived-webinars/no-more-cauti-transcript.html
December 01, 2017 - 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.
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2023-adverse-event-data-report.pdf
January 01, 2023 - Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022
PATIENT
SAFETY
Adverse Events
Among Medicare
Hospitalizations in
2021–2023
This page intentionally left blank.
…
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/evidence-based-reports/services/quality/patientsftyupdate/ptsafetysum.pdf
March 01, 2013 - “common;” examples include falls,
venous thromboembolism (VTE), potential adverse drug
events, or pressure … ulcers. … ulcers;
and PSPs designed to improve the overall system or to
address multiple patient safety targets … ulcers; in-depth review
Common/
Moderate
Moderate Negligible Moderate Moderate/
Moderate
9
Table … ulcers, and other
nursing sensitive outcomes (other than
mortality); in-depth review
Common/High
-
www.ahrq.gov/news/newsroom/case-studies/201411.html
August 01, 2014 - Mercy also replaced patient beds to reduce incidents of pressure ulcers and to promote patient and staff
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www.ahrq.gov/research/findings/final-reports/index.html?page=3
January 01, 2024 - Grant Number: R01 HS 22903 Topic(s): Pressure Ulcers Publication Date: June 2020
Occult Uterine
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - Smith (2)
Because of his immobility, he develops a pressure ulcer on his sacrum. … Urinary Catheter Harm is in the middle, with several issues surrounding it (i.e. immobility, CAUTI, pressure … ulcers), that could lead to Falls and VTE.
-
www.ahrq.gov/sites/default/files/2024-07/alexander-report.pdf
January 01, 2024 - sores; 4) who are at low risk and who
have pressure sores; 5) who are physically restrained; 6) who … sores. … Ulcers 13938 787 5.9 5.6
Who Lose Too Much Weight 14183 798 7.4 7.5
Bowel or Bladder Incontinent 13038 … Ulcers -0.01 -0.05 0.01 0.05 0.02 0.04 0.05 0.02 -0.01 0.01
Who Lose Too Much Weight 0.05 0.05 0.05 … Ulcers, and % Short Stay
Assessed/Given Pneumococcal Vaccine.
-
www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
April 01, 2018 - Delirium
2
427
-- Nosocomial Infections
3
450
-- Patient Falls
11
428
-- Pressure … Ulcers
5
430
-- Venous Thrombosis and Thromboembolism
0
414
Medication Safety
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives-notes.docx
April 01, 2022 - They are as follows:
· Stage III or stage IV or unstageable pressure ulcers
· Moderate to severe incontinence-associated … urinary retention with or without bladder outlet obstruction
· Stage III or stage IV or unstageable pressure … ulcer, or similarly severe wounds of other types, that cannot be kept clear of urinary incontinence
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-slides.pptx
January 01, 2017 - Estimated Additional Costs of Healthcare-Acquired Conditions (HACs)
Series 1 VAPs SSIs CLABSI Other HACs Pressure … Ulcers Post-op DVTs Falls Adverse Drug Events Obstetric Adverse Events CAUTI 21001 21000 17000 17000 … Sheet1
Series 1
VAPs $ 21,001
SSIs $ 21,000
CLABSI $ 17,000
Other HACs $ 17,000
Pressure … Ulcers $ 17,000
Post-op DVTs $ 8,000
Falls $ 7,234
Adverse Drug Events $ 5,000
Obstetric
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab7.html
December 01, 2012 - 5,672
13,799
7,174
Max
38,852
29,161
10,824
48,675
50,219
49,623
36,143
Pressure … Ulcer
3,905
2,269
1,404
2,683
4,903
4,190
3,485
Min
1,699
551
314
557
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4_pdi_bestpracticescover.pdf
June 02, 2025 - 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
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/intro.html
June 01, 2017 - Table 1 lists reports and implementation materials for pressure ulcer healing.
Table 1.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Cunningham_11.pdf
January 29, 2008 - ulcer (bed sores); or postoperative
sepsis (blood infection). … Decubitus ulcer
5. Failure to rescue
6. Foreign body left during procedure
7. … • Monitoring errors, such as bedsores, failure to rescue, and patient falls. … ulcer
monitoring error
• Increased
checking of
inpatients for
decubitus ulcers
• Monitoring … forms or
behavioral checklists
• Decubitus ulcer
incidence rate
feedback
• Supervisor praise
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2019qdr-core-measures-quality.pdf
January 01, 2019 - nursing home residents with a
urinary tract infection (MDS)
4.9% in 2013 2.2% in 2017 -18.2 0.003
Pressure … Ulcers Short-stay nursing home patients with new or
worsening pressure ulcers (MDS)
0.7% in 2013 … residents with
a catheter inserted and left in the bladder
(MDS)
3.4% in 2013 2.8% in 2017 -5.4 0.008
Pressure … Ulcers High-risk, long-stay nursing home patients with
pressure ulcer (MDS)
5.3% in 2013 4.8% in
-
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.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b2b_pdi_ratesgenbywin.pdf
March 01, 2016 - - 2.46621024
PDI 1 PDI #1 Accidental Puncture or Laceration Rate 1 2 0.5 0.05664000
PDI 2 PDI #2 Pressure … Ulcer Rate 0 1 0 0.15210459
PDI 3 PDI #3 Retained Surgical Item or Unretrieved Device Fragment 0 0 … Infection
0 0.117371
PDI #1 Accidental Puncture or
Laceration
1 2 0.5 0.05664000
PDI #2 Pressure … Ulcer Rate 0 1 0 0.000251 0 0.15210459 0 0.000436
PDI #3 Retained Surgical Item or
Unretrieved Device
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b2b_combo_ratesgenbywin.pdf
March 01, 2016 - Rate 0 0 - 0.0006572
PDI1 PDI #1 Accidental Puncture or Laceration Rate 0 0 - 0.00053522
PDI2 PDI #2 Pressure … 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 … Ulcer Rate 0 47 0 0.000832 0 0.000405 0 0.000379
PSI #4 Death Rate among Surgical
Inpatients with
-
www.ahrq.gov/policymakers/chipra/pubs/background-2012/backgrndapb.html
December 01, 2012 - 4.5,2
0010
Postoperative wound dehiscence (PDI 11) (AHRQ)
6,3
5,3.75
0005
Pressure … ulcer rate (PDI 2) (AHRQ)
7,3
6.5,3.75
0004
Accidental puncture or laceration (PDI 1
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form_Word_doc_for_html_only.doc
June 02, 2025 - MEDICAL CARE REFERRAL FORM
USE IN ALL SITUATIONS WHEN A RESIDENT HAS A NEW PROBLEM AND INFECTION MAY BE SUSPECTED, AND IS BEING REFERRED TO A MEDICAL CARE PROVIDER, INCLUDING TRANSFER TO AN EMERGENCY DEPARTMENT OR HOSPITAL.
To: _______________________________________________ Phone: ________________ Fax: ______________…