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  1. 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.
  2. 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. …
  3. 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 pressureulcers. … 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
  4. 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
  5. 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
  6. 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, pressureulcers), that could lead to Falls and VTE.
  7. 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.
  8. 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  -- PressureUlcers 5 430  -- Venous Thrombosis and Thromboembolism 0 414 Medication Safety
  9. 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 pressureulcer, or similarly severe wounds of other types, that cannot be kept clear of urinary incontinence
  10. 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 PressureUlcers 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 PressureUlcers $ 17,000 Post-op DVTs $ 8,000 Falls $ 7,234 Adverse Drug Events $ 5,000 Obstetric
  11. 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 PressureUlcer 3,905 2,269 1,404 2,683 4,903 4,190 3,485   Min 1,699 551 314 557
  12. 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 PressureUlcer Rate • PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count • PDI 05 Iatrogenic
  13. 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.
  14. 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
  15. 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 PressureUlcers 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 PressureUlcers High-risk, long-stay nursing home patients with pressure ulcer (MDS) 5.3% in 2013 4.8% in
  16. 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.
  17. 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 PressureUlcer 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 PressureUlcer Rate 0 1 0 0.000251 0 0.15210459 0 0.000436 PDI #3 Retained Surgical Item or Unretrieved Device
  18. 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 PressureUlcer 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 PressureUlcer 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
  19. 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 Pressureulcer rate (PDI 2) (AHRQ) 7,3 6.5,3.75   0004 Accidental puncture or laceration (PDI 1
  20. 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: ______________…

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