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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45011/psn-pdf
    May 25, 2016 - becoming-high-reliability-organization-operational-advice-hospital-leaders https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43151/psn-pdf
    April 30, 2014 - https://psnet.ahrq.gov/issue/serious-adverse-events-reports https://psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41554/psn-pdf
    January 03, 2017 - Using root cause analysis to reduce falls with injury in community settings. January 3, 2017 Lee A, Mills PD, Neily J. Using root cause analysis to reduce falls with injury in community settings. Jt Comm J Qual Patient Saf. 2012;38(8):366-374. https://psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-inj…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838916/psn-pdf
    October 26, 2022 - Falling through the cracks: the invisible hospital cleaning workforce. October 26, 2022 Hacker CE, Debono D, Travaglia J, et al. Falling through the cracks: the invisible hospital cleaning workforce. J Health Organ Manag. 2022;36(8):981-986. doi:10.1108/jhom-02-2022-0035. https://psnet.ahrq.gov/issue/falling-throu…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73398/psn-pdf
    June 30, 2021 - In healthcare design, sometimes we can fall into a routine that we think we know the answer, but we … patient getting up to go to the bathroom without calling a nurse and putting themselves at risk for a fall
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33655/psn-pdf
    August 01, 2007 - Challenge clinical quality leadership recommendations that fall short of the board's expectations for
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49667/psn-pdf
    October 01, 2012 - Many of the steps and techniques described above fall under the field of medication safety engineering
  8. psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
    July 31, 2023 - delivery. 17 Following up on pending tests or laboratory studies and informing providers of results may fall … Stopped Here June 1, 2004 WebM&M Cases Another Fall
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73604/psn-pdf
    August 18, 2021 - The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England. August 18, 2021 Damery S, Flanagan S, Jones J, et al. The effect of providing staff training and enhanced support to c…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49520/psn-pdf
    September 01, 2006 - psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72737/psn-pdf
    February 09, 2021 - Behavioral health may not fall within traditional funding and reimbursement mechanisms within your facility
  12. psnet.ahrq.gov/primer/opioid-safety
    December 15, 2024 - improve the safety of opioids have primarily focused on reducing inappropriate opioid prescribing and fall
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39650/psn-pdf
    June 30, 2010 - Negotiating safety when staffing falls short. June 30, 2010 Zolnierek CD, Steckel CM. Negotiating Safety when Staffing Falls Short. Crit Care Nurs Clin North Am. 2010;22(2). doi:10.1016/j.ccell.2010.03.014. https://psnet.ahrq.gov/issue/negotiating-safety-when-staffing-falls-short This commentary describes strategi…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37825/psn-pdf
    April 11, 2011 - The effect of bedrails on falls and injury: a systematic review of clinical studies. April 11, 2011 Healey F, Oliver D, Milne A, et al. The effect of bedrails on falls and injury: a systematic review of clinical studies. Age Ageing. 2008;37(4):368-78. doi:10.1093/ageing/afn112. https://psnet.ahrq.gov/issue/effect-…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44845/psn-pdf
    July 01, 2016 - Is single room hospital accommodation associated with differences in healthcare-associated infection, falls, pressure ulcers or medication errors? A natural experiment with non-equivalent controls. July 1, 2016 Simon M, Maben J, Murrells T, et al. Is single room hospital accommodation associated with differences i…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35808/psn-pdf
    June 19, 2007 - 100K Lives falling short. June 19, 2007 Robeznieks A. https://psnet.ahrq.gov/issue/100k-lives-falling-short This article reports on the progress of the 100,000 Lives Campaign and what has been learned thus far. https://psnet.ahrq.gov/issue/100k-lives-falling-short
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39129/psn-pdf
    November 25, 2009 - How to avoid falling victim to a hospital mistake. November 25, 2009 Cohen E. https://psnet.ahrq.gov/issue/how-avoid-falling-victim-hospital-mistake This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization. https://psnet.ahrq.g…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39734/psn-pdf
    November 14, 2011 - Man falls off surgical table; St. Joseph's Hospital sued. November 14, 2011 Smith ML; Wolfe WA. https://psnet.ahrq.gov/issue/man-falls-surgical-table-st-josephs-hospital-sued This newspaper article reports on a lawsuit regarding a safety incident that led to injury and subsequent death of a patient. https://psnet…
  19. psnet.ahrq.gov/issue/nurses-perceptions-safety-culture-long-term-care-settings
    April 06, 2011 - Study Nurses' perceptions of safety culture in long-term care settings. Citation Text: Wagner LM, Capezuti E, Rice JC. Nurses' perceptions of safety culture in long-term care settings. J Nurs Scholarsh. 2009;41(2):184-192. doi:10.1111/j.1547-5069.2009.01270.x. Copy Citation Format…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44641/psn-pdf
    October 26, 2016 - Resident Safety Practices in Nursing Home Settings. October 26, 2016 Simmons S, Schnelle J, Slagle J, et al. Technical Brief No. 24. Rockville, MD: Agency for Healthcare Research and Quality; May 2016. AHRQ Publication No. 16-EHC022-EF. https://psnet.ahrq.gov/issue/resident-safety-practices-nursing-home-settings E…

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