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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
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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
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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…
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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…
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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
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - Challenge clinical quality leadership recommendations that fall short of the board's expectations for
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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
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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
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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…
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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
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Behavioral health may not fall within traditional funding and
reimbursement mechanisms within your facility
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - improve the safety of opioids have primarily focused on reducing inappropriate opioid prescribing and fall
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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…
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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-…
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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…
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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
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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…
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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…
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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…
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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…