-
www.ahrq.gov/research/findings/final-reports/index.html?page=8
January 01, 2024 - Publication Date: March 2015
Using an Electronic Health Record To Examine Nurse Continuity and Pressure … Ulcers ( application/pdf 844258 ) Principal Investigators: Stifter, et al. … Coordination, Health Information Technology and Health Information Exchange, Human and Environmental Factors, Pressure … Ulcers Publication Date: December 2014
The Value of Hospital-Related Patient-Safety Interventions
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pdf
October 01, 2015 - ulcer)
• Denominator = population at risk (e.g., hospitalized
patients)
• Observed rate = numerator … 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)
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … An Example: Pressure Ulcer (PDI 02)�
How can the AHRQ PDIs be used in�quality assessment?
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17b.html
February 01, 2023 - 10,530
7,005
Composite: ACSC Overall
24,760
16,334
23,622
19,729
26,330
18,086
Pressure … Ulcer
4,583
2,937
4,303
3,638
4,774
3,353
Injurious Falls
397
350
396
366 … 8,314
8,522
10,408
7,479
Composite: ACSC Overall
21,408
21,005
25,803
19,316
Pressure … Ulcer
4,098
3,440
4,727
3,530
Injurious Falls
384
363
466
342
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17g.html
February 01, 2023 - 13,941
8,615
Composite: ACSC Overall
31,820
19,437
32,312
23,141
34,235
21,902
Pressure … Ulcer
5,156
2,917
5,215
3,604
5,195
3,597
Injurious Falls
568
461
588
484 … 10,221
11,658
13,626
9,337
Composite: ACSC Overall
25,759
28,549
32,778
23,897
Pressure … Ulcer
4,379
3,646
4,962
3,857
Injurious Falls
504
573
687
457
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17d.html
February 01, 2023 - 3,815
3,120
Composite: ACSC Overall
6,079
4,558
5,662
5,312
6,245
5,000
Pressure … Ulcer
1,619
1,071
1,367
1,440
1,749
1,185
Injurious Falls
81
60
90
55
92 … 3,481
3,208
3,831
3,228
Composite: ACSC Overall
5,719
5,011
6,399
5,136
Pressure … Ulcer
1,498
1,217
1,890
1,213
Injurious Falls
80
57
88
68
Notes:
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17c.html
February 01, 2023 - 5,049
3,932
Composite: ACSC Overall
15,281
10,642
14,988
12,306
15,447
12,117
Pressure … Ulcer
2,935
1,376
2,649
2,045
3,140
1,790
Injurious Falls
76
51
101
45
98 … 4,416
4,102
5,111
4,002
Composite: ACSC Overall
13,885
11,778
15,231
12,519
Pressure … Ulcer
2,200
2,447
3,298
1,833
Injurious Falls
66
63
119
44
Notes:
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17.html
February 01, 2023 - 9,215
6,184
Composite: ACSC Overall
22,374
14,832
21,534
17,751
23,720
16,492
Pressure … Ulcer
4,168
2,525
3,903
3,214
4,382
2,935
Injurious Falls
316
271
324
280 … 7,298
7,429
9,114
6,570
Composite: ACSC Overall
19,447
18,724
23,221
17,538
Pressure … Ulcer
3,603
3,194
4,378
3,086
Injurious Falls
301
289
382
264
Notes
-
psnet.ahrq.gov/node/41344/psn-pdf
June 15, 2012 - issue/review-patient-safety-incidents-reported-critical-care-units-north-west-england-
2009-and-2010
Pressure … ulcers were the most common voluntarily reported patient safety issue in intensive care units in
this
-
psnet.ahrq.gov/node/41985/psn-pdf
October 26, 2016 - The most common adverse events reported were pressure ulcers and fall-
related injuries or deaths.
-
psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - myocardial infarct, stroke, and pulmonary
embolism (kappa>0.8) than on the timing of renal failure, decubitus … ulcers in addition to stage 3 or 4 ulcers acquired after admission. … However, only 25% of the last
16 reported patients had an ICD-9-CM secondary diagnosis code of a pressure … ulcer (codes
707.00–707.09). … Our
administrative system has a limitation of 15 diagnoses, and it is possible that the decubitus ulcer
-
psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - include delayed or omitted medications or
treatments; complications such as atelectasis, deconditioning, pressure … ulcers, falls, ventilator-associated
pneumonia, or other nosocomial infections; increased length of … significant impacts were demonstrated on medication errors, patient falls,
nosocomial infections, pressure … ulcers, mortality, and patient satisfaction.
-
psnet.ahrq.gov/node/47849/psn-pdf
August 14, 2019 - found that enhanced accreditation procedures in the United
Kingdom did not improve rates of either pressure … ulcers or falls.
-
psnet.ahrq.gov/node/60223/psn-pdf
January 01, 2021 - The authors found that the harms with the highest 30-day readmission rates were
pressure ulcers (45%
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/b4_pdi_documentationcoding.pdf
March 15, 2016 - ulcers). … ulcers or CLABSI, deaths, oncology patients). … PDI 02 Pressure Ulcer Rate (stage
III, IV, Unstageable)
Diagnosis and site of pressure ulcer must … PDI 02 Pressure Ulcer X If the ulcer progresses from one stage
to another higher stage during the
encounter … Provider must document the site of
pressure ulcer; the stage of the ulcer
can be documented and coded
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/preventing-cauti-icu-051314.pptx
February 07, 2014 - Now immobile and developed pressure ulcers worsened by diarrhea. … They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient … ulcers
Immobility
Aims
9
Understand the CUSP framework for initiating culture change … Now immobile and developed pressure ulcers worsened by diarrhea. … They also immobilize patients—increasing the likelihood of pressure ulcers, falls and prolonged inpatient
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17f.html
February 01, 2023 - 7,139
5,429
Composite: ACSC Overall
23,940
16,507
25,790
18,529
23,803
18,978
Pressure … Ulcer
5,875
3,508
6,077
4,338
6,250
4,022
Injurious Falls
147
123
175
119 … 6,119
6,072
7,171
5,539
Composite: ACSC Overall
21,607
19,235
23,468
19,546
Pressure … Ulcer
4,785
5,171
6,257
4,181
Injurious Falls
145
120
171
121
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab17e.html
February 01, 2023 - 8,838
5,914
Composite: ACSC Overall
20,734
15,368
19,563
17,756
23,009
16,087
Pressure … Ulcer
2,980
2,213
2,877
2,492
3,415
2,252
Injurious Falls
253
224
263
220 … 6,956
7,098
7,925
6,580
Composite: ACSC Overall
19,175
17,427
20,509
17,826
Pressure … Ulcer
2,820
2,361
3,195
2,436
Injurious Falls
251
221
300
217
Notes
-
hcup-us.ahrq.gov/reports/methods/2011_05.pdf
January 01, 2011 - The
reduction in rates for five PSIs was statistically significant: decubitus ulcer, foreign body
left … Importantly,
when POA information was incorporated, most cases of decubitus ulcer, post-operative
hip … The study assessed rates of four PSIs – decubitus ulcer, infections due to
medical care, postoperative … Several ideas and tools are suggested to
assist providers in staging pressure ulcers including the use … Of
the last 16 reported patients with a pressure ulcer, only 25% were recorded with an ICD-
9-CM pressure
-
www.ahrq.gov/action-alliance/resources/type-harm.html
September 01, 2025 - Falls Healthcare-Associated Infections Maternal Safety Medication Safety Never Events Opioid Safety Pressure … Ulcers Readmissions Sepsis Surgical Safety Transitions in Care Venous Thromboembolism Diagnostic Safety … Back to Contents Pressure Ulcers AHRQ Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving … Quality of Care This resource assists hospital staff in implementing effective pressure ulcer prevention
-
psnet.ahrq.gov/node/866526/psn-pdf
August 14, 2024 - Common adverse events impacting this
population include adverse drug events, delirium, malnutrition, pressure … ulcers, and infections.