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Showing results for "fall".
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  1. "Please describe from your point of view a typical case of an error in palliative care": qualitative data from an exploratory cross-sectional survey study among palliative care professionals. | PSNet

    psnet.ahrq.gov/issue/please-describe-your-point-view-typical-case-error-palliative-care-qualitative-data
    December 04, 2016 - Study "Please describe from your point of view a typical case of an error in palliative care": qualitative data from an exploratory cross-sectional survey study among palliative care professionals. Citation Text: Dietz I, Plog A, Jox RJ, et al. "Please describe from your point of view a …

  2. Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. | PSNet

    psnet.ahrq.gov/issue/electronic-surveillance-and-pharmacist-intervention-vulnerable-older-inpatients-high-risk
    March 21, 2017 - Study Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. Citation Text: Peterson JF, Kripalani S, Danciu I, et al. Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medicatio…

  3. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. | PSNet

    psnet.ahrq.gov/issue/incidence-and-nature-adverse-events-during-pediatric-sedationanesthesia-procedures-outside
    March 01, 2011 - Study Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Citation Text: Cravero JP, Blike G, Beach M, et al. Incidence and nature of adverse events during pediatr…

  4. Improving hospital infant safe sleep compliance by using safety prevention bundle methodology. | PSNet

    psnet.ahrq.gov/issue/improving-hospital-infant-safe-sleep-compliance-using-safety-prevention-bundle-methodology
    March 09, 2022 - Study Improving hospital infant safe sleep compliance by using safety prevention bundle methodology. Citation Text: Batra EK, Lewis ML, Saravana D, et al. Improving hospital infant safe sleep compliance by using safety prevention bundle methodology. Pediatrics. 2021;148(6):e2020033704. d…

  5. The standardisation of handoffs in a large academic paediatric emergency department using I-PASS. | PSNet

    psnet.ahrq.gov/issue/standardisation-handoffs-large-academic-paediatric-emergency-department-using-i-pass
    October 21, 2020 - Study The standardisation of handoffs in a large academic paediatric emergency department using I-PASS. Citation Text: Chladek MS, Doughty C, Patel B, et al. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual. 2021;10(3):e00125…

  6. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

    psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
    March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. Citation Text: Clifford SP, Mick PB, Derhake BM. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional ch…

  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. Using root cause analysis to reduce falls with injury in community settings. | PSNet

    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. 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 …

  14. 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…

  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…
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