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421. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
     September 01, 2017 - ulcer, fall risk, late-loss ADL index score greater than or equal to 12 [based on RUG-III], cognitive … ulcer, fall risk, late-loss ADL index score greater than or equal to 12 [based on RUG-III], cognitive … ulcer, and two medical conditions (cellulitis and hypertension) would trigger Rule 2. … Presence of stage 2 or greater pressure ulcer. … If there is a pressure ulcer stage 2, 3, 4, or unstageable recorded as present within 7 days of the report

422. Appendix B7: Wheelchair Seating Assessment (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manwsa.html
     December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix B7: Wheelchair Seating Assessment (Text Description) Previous Page Next Page Table of Contents The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Chapter 1. Introductio…

423. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits - Transfer Note and Intake Note (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.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

424. 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-oct-rev.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.

425. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.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.

426. Engineering Safe Practices Affinity Group | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/engineering-safety-practice/index.html
     April 01, 2025 - . * Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care . * OSHA Safe Patient

427. Fact Sheet on Patient Safety Indicators (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a1b_combo_psifactsheet.pdf
     October 01, 2015 - Year PSI 02 Death Rate in Low-Mortality Diagnosis- Related Groups (DRGs) 0.32 0347 2012 PSI 03 Pressure … Ulcer Rate 0.50 PSI 04 Death Rate Among Surgical Inpatients with Serious Treatable Complications

428. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
     January 01, 2025 - states, however; for example, abuse incidents are taken very seriously, but falls, other incidents, and pressure … ulcers are not. … Compared to 38.5% surveyor visits for burns and 22.7% for pressure ulcers, the numbers are fairly low … ulcers are not. … ulcers 26 38.4 4.0 49.2 8.5 22 18.2 9.1 50.0 22.7 Burns 26 12.1 4.4 65.4 18.1 26 11.5 0.0 50.0 38.5

429. Improving the Value of Patient Safety Reporting Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Pronovost_95.pdf
     June 12, 2008 - taxonomies include mistakes (e.g., prescribing errors) and the outcome of mistakes (e.g., p falls, decubitus … ulcers) as event types. … However, falls and decubitus ulcers are visible ha (outcomes) that might have resulted from failure to … the proportion of incidents in the ICUSRS with harm identified, it is not surprising that falls and decubitus … ulcers were among the highest.

430. Part Two: Removing the Obstacles to Practice Change | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/ena-slides/part2.html
     October 01, 2020 - While a catheter may prove useful in advanced-stage pressure ulcers, there are many other products that

431. Quality Indicators Sensitive to Nurse Staffing in Acute Care Settings (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Savitz.pdf
     March 01, 2004 - overarching indicators related to medication administration errors, nosocomial infections, patient falls, pressure … ulcers, and mortality, with increasing detail in measure specification.11 For example, nosocomial … accepted n=7) Provisional NQF (n=13) ANA (n=10) Death in low mortality DRG X Decubitus/pressure … ulcer X X X Failure to rescue X X X Infection due to medical care X • Urinary tract infection … We see virtually no direct overlap in these measure sets, with the exception of decubitus/pressure ulcer

432. On-Time Preventable Hospital and Emergency Department Visits (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/2-preventablehospitalandedvisits-samplerpts_3.pdf
     November 30, 2013 - • Current clinical conditions contributing to transfer risk: use of oxygen, catheter or ostomy, any pressure … ulcer other than stage I, fall risk, late-loss activities of daily living (ADL) score greater than or … ulcer. • Fall risk or previous fall in last 90 days. • Late-loss ADL score ≥12. • Cognitive impairment … active medications during the report week, active high-risk diagnosis of UTI, presence of Stage III pressure … ulcer, and two medical conditions, cellulitis and hypertension, would trigger Rule 2. 3.

433. Preventing CAUTI in Specialized Patient Populations: The ICU | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-specialized-populations-icu.html
     December 01, 2017 - they were also that because of her immobility and functional incontinence that she might develop a pressure … ulcer or skin breakdown. … She started to get decubitus ulcers from her immobility, very stage I stage II decubitus ulcers. … And then she gets the CAUTI, which results in C. diff , which results in a pressure ulcer, increased

434. Paul Tedrick (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-transcript.doc
     May 13, 2014 - they were also that because of her immobility and functional incontinence that she might develop a pressure … ulcer or skin breakdown. … She started to get decubitus ulcers from her immobility, very stage I stage II decubitus ulcers. … And then she gets the CAUTI, which results in C. diff, which results in a pressure ulcer, increased length

435. Slide 1 (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/patient-family-centered-care-040913.ppt
     June 02, 2025 - of the Council * Welcome Video to welcome new patients to the hospital C- Diff flyer Brochure on Pressure … Ulcers Noise Reduction Sleep Time Sign Nurse Residency Program- Testimonials Food and Quality Improvements

436. A New Model of Tracheostomy Care: Closing the Research–Practice Gap (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Clair.pdf
     January 01, 2004 - The WRAMC Department of Nursing is presently developing similar evidence-based procedures for pressure … ulcer prevention, deep vein thrombosis prophylaxis, and for enteral feeding. … Ongoing and future projects funded through the TriService Nursing Research Program (TSNRP) include pressure … ulcer prevention, deep vein thrombosis prophylaxis, and enteral feeding precautions to reduce aspiration

437. Pediatric Toolkit for Using the AHRQ Quality Indicators | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/pediatric.html
     December 01, 2017 - Introduction PDF [ - 38.47 KB] PDI01 Accidental Puncture or Laceration PDF [ - 62.74 KB] PDI02 Pressure … Ulcer PDF [ - 110.08 KB] PDI03 Foreign Body PDF [ -96.96 KB] PDI05/NQI01 Iatrogenic Pneumothorax

438. Part 3: National Quality Strategy Priority—Patient Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/nhqrdr/chartbooks/blackhealth/part3-nqs2.html
     June 01, 2018 - are restrained can become weak, lose their ability to go to the bathroom by themselves, and develop pressure … ulcers or other medical conditions.

439. BLADDER SCAN – POLICY #2202 12/11/06 (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.docx
     March 01, 2017 - . · Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral

440. Appendix F. CAUTI Prevention in Long-Term Care: Frequently Asked Questions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.html
     March 01, 2017 - Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral wounds