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401. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837863/psn-pdf
     August 17, 2022 - The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide. August 17, 2022 Portland, OR: Oregon Patient Safety Commission; 2022.  https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide Patient falls are common sentinel events. The latest revis…

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50862/psn-pdf
     February 05, 2020 - Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare. February 5, 2020 Sanghavi P, Pan S, Caudry D. Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare. Health Serv Res. 2020;55(2):201-210. doi:10.1111/1475-…

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48116/psn-pdf
     July 17, 2019 - Awareness and confidence in patient safety topics including medication safety and fall prevention improved

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852463/psn-pdf
     August 16, 2023 - Actions such as working with a care partner, tracking medications, and recognizing fall risks can protect

405. Exploring organizational context and structure as predictors of medication errors and patient falls. | PSNet
     psnet.ahrq.gov/issue/exploring-organizational-context-and-structure-predictors-medication-errors-and-patient-falls
     January 22, 2020 - Study Exploring organizational context and structure as predictors of medication errors and patient falls. Citation Text: Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). …

406. Implementing a survey for patients to provide safety experience feedback following a care transition: a feasibility study | PSNet
     psnet.ahrq.gov/issue/implementing-survey-patients-provide-safety-experience-feedback-following-care-transition
     January 08, 2020 - with diabetes being discharged from hospital October 16, 2019 The impact of post-fall … huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a

407. Impact of the primary care nurse manager on nurse intent to leave and staff perception of patient safety. | PSNet
     psnet.ahrq.gov/issue/impact-primary-care-nurse-manager-nurse-intent-leave-and-staff-perception-patient-safety
     November 01, 2023 - September 23, 2020 A randomized trial of a multifactorial strategy to prevent serious fall … September 8, 2021 A randomized trial of a multifactorial strategy to prevent serious fall

408. Differences in donor heart acceptance by race and gender of patients on the transplant waiting list. | PSNet
     psnet.ahrq.gov/issue/differences-donor-heart-acceptance-race-and-gender-patients-transplant-waiting-list
     January 12, 2022 - Related Resources From the Same Author(s) Evaluation of clinical practice guidelines on fall … August 4, 2021 A randomized trial of a multifactorial strategy to prevent serious fall

409. Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. | PSNet
     psnet.ahrq.gov/issue/outbreak-investigation-covid-19-among-residents-and-staff-independent-and-assisted-living
     October 19, 2022 - August 17, 2016 A randomized trial of a multifactorial strategy to prevent serious fall … Organization's Approach October 1, 2007 Evaluation of clinical practice guidelines on fall

410. Association of default electronic medical record settings with health care professional patterns of opioid prescribing in emergency departments: A randomized quality improvement study | PSNet
     psnet.ahrq.gov/issue/association-default-electronic-medical-record-settings-health-care-professional-patterns
     February 12, 2020 - May 17, 2023 Balancing safety, comfort, and fall risk: an intervention to limit opioid … Journal Article Study Catching those who fall

411. Safe use of health information technology. | PSNet
     psnet.ahrq.gov/issue/safe-use-health-information-technology
     December 23, 2016 - Citation Related Resources From the Same Author(s) Preventing falls and fall-related … February 8, 2017 Preventing falls and fall-related injuries in health care facilities

412. Falling through the cracks: the invisible hospital cleaning workforce. | PSNet
     psnet.ahrq.gov/issue/falling-through-cracks-invisible-hospital-cleaning-workforce
     June 19, 2013 - Commentary Falling through the cracks: the invisible hospital cleaning workforce. Citation Text: 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. Copy…

413. Nursing practice with hospitalised older people: safety and harm. | PSNet
     psnet.ahrq.gov/issue/nursing-practice-hospitalised-older-people-safety-and-harm
     April 24, 2018 - March 6, 2013 Evaluation of clinical practice guidelines on fall prevention and management … August 7, 2019 Fall prevention in hospitals: an integrative review.

414. Improving operating room and perioperative safety: background and specific recommendations. | PSNet
     psnet.ahrq.gov/issue/improving-operating-room-and-perioperative-safety-background-and-specific-recommendations
     August 29, 2011 - August 19, 2020 Evaluation of clinical practice guidelines on fall prevention and management … July 13, 2010 A randomized trial of a multifactorial strategy to prevent serious fall

415. Physician Quality Officer: a new model for engaging physicians in quality improvement. | PSNet
     psnet.ahrq.gov/issue/physician-quality-officer-new-model-engaging-physicians-quality-improvement
     May 03, 2017 - September 14, 2016 Safety standards: implementing fall prevention interventions and sustaining … lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit.

416. Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. | PSNet
     psnet.ahrq.gov/issue/clinical-uncertainty-primary-care-challenge-collaborative-engagement
     December 23, 2008 - December 21, 2017 Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) … program to engage older adults in fall prevention in a nursing home.

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38715/psn-pdf
     February 17, 2011 - Medicare nonpayment, hospital falls, and unintended consequences. February 17, 2011 Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-3. doi:10.1056/NEJMp0900963. https://psnet.ahrq.gov/issue/medicare-nonpayment-hospital-falls-and-uni…

418. A model of recovering medical errors in the coronary care unit. | PSNet
     psnet.ahrq.gov/issue/model-recovering-medical-errors-coronary-care-unit
     June 02, 2010 - January 27, 2021 Fall prevention in acute care hospitals: a randomized trial. … Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall

419. Enhancing pediatric perioperative patient safety. | PSNet
     psnet.ahrq.gov/issue/enhancing-pediatric-perioperative-patient-safety
     January 28, 2015 - Talking about falls: a qualitative exploration of spoken communication of patients' fall … risks in hospitals and implications for multifactorial approaches to fall prevention.

420. Medical errors recovered by critical care nurses. | PSNet
     psnet.ahrq.gov/issue/medical-errors-recovered-critical-care-nurses
     June 04, 2008 - January 27, 2021 Fall prevention in acute care hospitals: a randomized trial. … Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall