Skip to Main Content


The information contained in these resources does not necessarily reflect the views of the Partnership for Patients, the Centers for Medicare and Medicaid Services, The United States Department of Health and Human Services, nor the United States government.

Pressure Ulcers
Title Description
“National Guideline Clearinghouse: Pressure ulcer prevention and treatment. Health care protocol." (U.S. Department of Health & Human Resources, Agency for Healthcare Research and Quality [AHRQ]) A comprehensive update of a previous guideline by the Institute for Clinical Systems Improvement, designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients.
“National Guideline Clearinghouse: Prevention of Pressure Ulcers” (AHRQ) A direct comparison of recommendations for the prevention of pressure ulcers presented in two guidelines: "Preventing pressure ulcers and skin tears" by the Hartford Institute for Geriatric Nursing, and "Guideline for prevention and management of pressure ulcers" by the Wound, Ostomy, and Continence Nurses Society.
“Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care” (AHRQ) A toolkit designed to assist hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care, and created with the assistance of quality improvement teams at six medical centers: Billings Clinic, Boston Medical Center, Denver Health Medical Center, Montefiore Medical Center, VA Connecticut Healthcare System (West Haven Campus), and VA North Texas Healthcare System (Dallas Campus).
“National Guideline Clearinghouse: ‘Risk Assessment’ and ‘Prevention of Pressure Ulcers’” (AHRQ) Search result listing of 92 clinical and best practice guidelines that deal with ‘risk assessment’ and ‘prevention of pressure ulcers.’
“On-Time Pressure Ulcer Healing Project” (AHRQ) The project is intended to improve nursing home care. The focus is on prevention and timely treatment during routine care. The program has been expanded to include new tools to document pressure ulcer healing and treatments and reports to help monitor the healing process.
“Pressure Ulcers: A Patient Safety Issue” Patient Safety and Quality: An Evidence-Based Handbook for Nurses (2008), Chapter 12 (AHRQ) [PDF, 198KB] Evidence-based handbook for nurses.
“How-to Guide: Prevent Pressure Ulcers” (Institute for Healthcare Improvement [IHI]) How-to guide describes key evidence-based care components for preventing pressure ulcers, describes how to implement the interventions, and recommends measures to gauge improvement.
“Pressure Ulcer Prevention” (IHI) Quick reference table to find a mentor hospital for pressure ulcer prevention with demographics similar to the searcher’s. The organizations on the IHI Mentor Registry have volunteered to provide support, advice, clinical expertise, and tips to hospitals seeking help with their implementation efforts.
“SAFE SKIN Call to Action” (Minnesota Hospital Association) The Minnesota Hospital Association is conducting a “SAFE SKIN” initiative aimed at preventing serious pressure ulcers in hospital patients. It includes resources of best clinical practices and a special tool kit of information.
“Pressure Ulcers” (PatientCareLink) PatientCareLink is a joint effort of the Massachusetts Hospital Association and the Organization of Nurse Leaders to develop programs/initiatives in pressure ulcer prevention that focus on initial risk assessment, and then reassessments of patients, followed by a multi-pronged approach to preventing pressure ulcers in high risk patients. The program/initiatives include the involvement of wound and skin specialists to provide patient consultation and staff education.
“WOCN® Public Library” (Wound Ostomy and Continence Nurses Society) Information contained in the WOCN® Society’s Library has been developed and researched by leaders in the field of WOC care and often undergo an extensive content validation process to secure best practice standards. Accessible in the Public Library:
  • The Journal of Wound, Ostomy and Continence Nursing
  • Position Statements
  • Fact Sheets
  • White Papers
“Resources” (National Pressure Ulcer Advisory Panel) Pressure ulcer category/staging illustrations, free resources, international pressure ulcer guideline, PUSH tool, quick reference guides for prevention and treatment.
New Opportunities to Improve Pressure Ulcer Prevention and Treatment: Implications of the CMS Inpatient Hospital Care Present on Admission (POA) Indicators/Hospital-Acquired Conditions (HAC) Policy (International Expert Wound Care Advisory Panel) Consensus Paper from the International Expert Wound Care Advisory Panel. An examination of how the October 2008 changes in Medicare payment practice provided a compelling reason to review pressure ulcer prevention strategies.
“2007 National Patient Safety Goals” (The Joint Commission) [PDF, 61KB] In 2007 The Joint Commission established prevention of pressure ulcers as a National Patient Safety Goal.
“How-to Guide: Prevent Pressure Ulcers — Pediatric Supplement” (IHI) How-to guide specifically tailored for pediatrics describes key evidence-based care components for preventing pressure ulcers, describes how to implement these interventions, and recommends measures to gauge improvement.

Case Studies

Case Studies
Title Description
“Innovations Exchange: Pressure Ulcers” (AHRQ) A comprehensive collection of 34 innovations and quality tools for preventing and treating pressure ulcers.
“Stepping it up: Reducing Pressure Ulcers” (Hospitals in Pursuit of Excellence [HPOE]) Case study: Fairfield Medical Center, Lancaster, OH.
“Save Our Skin: Preventing Pressure Ulcers” (HPOE) Case study: OSF St. Francis Medical Center, Peoria, IL.
“Decreasing Pressure Ulcers Through Skin Care” (HPOE) Case study: Buena Vista Regional Medical Center, Storm Lake, IA.
“Reducing Pressure Ulcers” (HPOE) Case study: Bronson Methodist Hospital, Kalamazoo, MI.
“Champions Improve Staff Education and Compliance with Pressure Ulcer Prevention Strategies” (IHI) Case study: Onslow Memorial Hospital, Jacksonville, NC.

Go to Resources