Hospital-Acquired Pressure Ulcers: Results from the National Medicare Patient Safety Monitoring System Study


Address correspondence to Courtney H. Lyder, Los Angeles School of Nursing, University of California, 700 Tiverton Avenue, Factor Building, 2–256, Los Angeles, CA 90095. E-mail:



To determine the national and state incidence levels of newly hospital-acquired pressure ulcers (PUs) in Medicare beneficiaries and to describe the clinical and demographic characteristics and outcomes of these individuals.


Retrospective secondary analysis of the national Medicare Patient Safety Monitoring System (MPSMS) database.


Medicare-eligible hospitals across the United States and select territories.


Fifty-one thousand eight hundred forty-two randomly selected hospitalized fee-for-service Medicare beneficiaries discharged from the hospital between January 1, 2006, and December 31, 2007.


Data were abstracted from the MPSMS, which collects information on multiple hospital adverse events.


Of the 51,842 individuals in the MPSMS 2006/07 sample, 2,313 (4.5%) developed at least one new PU during their hospitalization. The mortality risk–adjusted odds ratios were 2.81 (95% confidence interval (CI) = 2.44–3.23) for in-hospital mortality, 1.69 (95% CI = 1.61–1.77) for mortality within 30 days after discharge, and 1.33 (95% CI = 1.23–1.45) for readmission within 30 days. The hospital risk–adjusted main length of stay was 4.8 days (95% CI = 4.7–5.0 days) for individuals who did not develop PUs and 11.2 days (95% CI = 10.19–11.4) for those with hospital-acquired PUs (< .001). The Northeast region and Missouri had the highest incidence rates (4.6% and 5.9%, respectively).


Individuals who developed PUs were more likely to die during the hospital stay, have generally longer hospital lengths of stay, and be readmitted within 30 days after discharge.