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  1. psnet.ahrq.gov/issue/effect-distractions-operative-performance-and-ability-multitask-case-deliberate-practice
    September 15, 2010 - Study Effect of distractions on operative performance and ability to multitask—a case for deliberate practice. Citation Text: Ahmed A, Ahmad M, Stewart M, et al. Effect of distractions on operative performance and ability to multitask--a case for deliberate practice. Laryngoscope. 2015;1…
  2. www.ahrq.gov/news/newsroom/case-studies/coe1304.html
    April 01, 2013 - Maryland Guides Prescribers on Use of Atypical Antipsychotic Medications Search All Impact Case Studies April 2013 The Maryland Department of Health and Mental Hygiene used materials created by AHRQ's Effective Health Care Program to help set up a new program for appropriate use of antipsychotic medications…
  3. www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap2b.html
    October 01, 2014 - Improving Patient Safety in Long-Term Care Facilities Appendix 2-B. Pre/Post-Test Questions and Answers for Module 2 Previous Page Next Page Table of Contents Improving Patient Safety in Long-Term Care Facilities Introduction Module 1. Detecting Change in a Resident's Condition Module 2. Commu…
  4. www.ahrq.gov/news/blog/ahrqviews/financial-strains-healthcare.html
    November 01, 2023 - AHRQ Views: Blog posts from AHRQ leaders Biden Administration Tackles Financial Strains on Healthcare Consumers NOV 30 2023 By Robert Otto Valdez, Ph.D., M.H.S.A. Robert Otto Valdez, Ph.D., M.H.S.A. Americans have long been facing a healthcare affordability crisis. …
  5. psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center-transforming-healthcare
    October 19, 2016 - Book/Report Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. Citation Text: Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. Chicago, IL: Health Resea…
  6. www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/vitamin-d-calcium-falls-bulletin.pdf
    January 21, 2025 - Task Force Issues Draft Recommendation Statement on Vitamin D and Calcium to Prevent Falls and Fractures in Older Adults 1 www.uspreventiveservicestaskforce.org Task Force Issues Draft Recommendation Statement on Vitamin D and Calcium to Prevent Falls and Fractures in Older Adults Vitamin D and calcium s…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50647/psn-pdf
    November 06, 2019 - ‘Fear of falling’: how hospitals do even more harm by keeping patients in bed. November 6, 2019 Bailey M. Kaiser Health News. October 17, 2019. https://psnet.ahrq.gov/issue/fear-falling-how-hospitals-do-even-more-harm-keeping-patients-bed Patient falls with harm are a common sentinel event. This news story discuss…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47901/psn-pdf
    April 10, 2019 - A systematic review of falls in hospital for patients with communication disability: highlighting an invisible population. April 10, 2019 Hemsley B, Steel J, Worrall L, et al. A systematic review of falls in hospital for patients with communication disability: Highlighting an invisible population. J Safety Res. 20…
  9. 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…
  10. 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-…
  11. psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings
    April 25, 2016 - Study Using root cause analysis to reduce falls with injury in community settings. Citation Text: 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. Copy Citation Format: Goo…
  12. 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…
  13. 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…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73363/psn-pdf
    June 09, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. June 9, 2021 Hada A, Coyer F. Shift?to?shift nursing handover interventions associated with improved inpatient outcomes—falls, pressure …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37792/psn-pdf
    February 15, 2011 - Exploring organizational context and structure as predictors of medication errors and patient falls. February 15, 2011 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). doi:10.1097/pts.0b013e3181695671.…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37518/psn-pdf
    March 13, 2008 - Innovation in patient safety: a new task design in reducing patient falls. March 13, 2008 Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5. https://psnet.ahrq.gov/issue/innovation-patient-safety…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40454/psn-pdf
    June 01, 2012 - Influence of unit-level staffing on medication errors and falls in military hospitals. June 1, 2012 Breckenridge-Sproat S, Johantgen M, Patrician PA. Influence of unit-level staffing on medication errors and falls in military hospitals. West J Nurs Res. 2012;34(4):455-74. doi:10.1177/0193945911407090. https://psne…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39255/psn-pdf
    February 02, 2011 - The patient who falls: "It's always a trade-off." February 2, 2011 Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024. https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade Through a case study, this article reviews evidence on risk…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47508/psn-pdf
    October 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018 Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372. https://psnet.ahrq.go…
  20. 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…