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401. Recommendations to Improve Children's Health Care Quality Measures | Agency for Healthcare Research and Quality
     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

402. Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety (pdf file)
     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

403. IQI, PSI, AND PDI RATES GENERATED BY THE AHRQ WINDOWS QI SOFTWARE (pdf file)
     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

404. 2019 National Healthcare Quality and Disparities Report Quality Trends (pdf file)
     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

405. 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 - 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*

406. 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 - 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*

407. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report.pdf
     January 01, 2022 - example, maternal-related AE can only be evaluated in a subset of all the sampled claims, while fall and pressure … ulcer can be evaluated from all claims.

408. NICU Family Information Packet, Appendix B, Tracheostomies (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-trache.pdf
     June 02, 2025 - NICU Family Information Packet, Appendix B, Tracheostomies Tracheostomies Tracheostomy Basics ■ Indications: upper airway obstruction, long term ventilation, ease of pulmonary toilet, to protect the airway. ■ Tube selection based on: – Indication for tracheostomy. – Tracheal width/length/shape. – Upper a…

409. Supportive and Palliative Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/supportive.html
     June 01, 2018 - Weight loss also may lead to muscle wasting, infections, and increased risk of pressure ulcers.

410. PowerPoint Presentation
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhosp-reports-slides.pptx
     November 30, 2013 - Kidney infection Medication reaction Mental status change Mental disorder/psychosis Neoplasm Pneumonia Pressure … ulcer Peripheral vascular disease Respiratory, other nonpneumonia Renal disease Seizure Sepsis/urosepsis … showing 15 active medications during the report week, active high-risk diagnosis of UTI, stage III pressure … ulcer, and two medical conditions: cellulitis and hypertension Rules for Determining High Risk Rule … Ulcer Fall Risk Late-Loss ADL Score ≥12 Cognitive Impairment Medical Conditions** High-Risk Medications

411. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
     January 01, 2010 - Smith (2) Because of his immobility, he develops a pressure ulcer on his sacrum. … would protect the skin in the incontinent patient, and a catheter may prove useful in advanced stage pressure … ulcers, but to protect intact skin, there are many other products that can create a barrier.

412. PQMP Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/measures/index.html
     June 09, 2025 - Measurement (CEPQM) NQF Endorsement Number: 3136 Initial Risk Assessment for Immobility-Related Pressure … Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission Measure Subdomain: Management

413. 4 Tk2 T1-Medical Care Referral Form (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
     May 01, 2014 - Advancing Excellence in Health Care www.ahrq.gov Agency for Healthcare Research and Quality 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 HOSPIT…

414. PQMP Measures | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/measures/index.html?page=0
     Measurement (CEPQM) NQF Endorsement Number: 3136 Initial Risk Assessment for Immobility-Related Pressure … Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission Measure Subdomain: Management

415. Sampleransferandintakenotes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
     June 02, 2025 - Medication reaction  Mental status change  Mental disorder/psychosis  Neoplasm  Pneumonia  Pressure … ulcer  Peripheral vascular disease  Respiratory, other nonpneumonia  Renal disease  Seizure

416. Preventing Device-Associated Infections | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/phys-championsgd/section4.html
     October 01, 2015 - associated with many infectious and noninfectious complications including immobility (with potential pressure … ulcers and increased risk for thromboembolism), trauma, and debility.

417. 115-Daily-Goals-Icu-Checklist (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/115-daily-goals-icu-checklist.docx
     October 01, 2024 - AHRQ Safety Program for MRSA Prevention Intensive Care Unit (ICU) Daily Goals Checklist ICU & Non-ICU Problem statement: Clear communication among healthcare providers is essential. Communication failures lead to patient harm, increased length of stay, provider dissatisfaction, and staff turnover. Effective communic…

418. AHRQ Views: Celebrating the 40th Anniversary of the U.S. Preventive Services Task Force | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/920.html
     July 01, 2024 - 36 states from AHRQ’s Healthcare Cost and Utilization Project focusing on adverse outcomes such as pressure … ulcers and mortality rates for conditions like heart failure and hip fracture.

419. 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/ereport-handouts.html
     June 01, 2017 - status change |___| Mental disorder/psychosis |___| Neoplasm |___| Pneumonia |___| Pressure … ulcer |___| Peripheral vascular disease |___| Respiratory, other nonpneumonia |___| Renal

420. Preventablehospitalandedvisits-Implmatl (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/preventablehospitalandedvisits-implmatl.pdf
     June 03, 2025 - status   Oxygen dependency   Confusion/mental status change   Any full thickness wound (e.g., pressure … ulcers [Stage II or greater], surgical wound, stasis ulcer)   Polypharmacy (15 or more medications … Chronic pressure ulcers Yes  No  L. Recurrent UTI Yes  No  M. Anemia Yes  No  N.