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psnet.ahrq.gov/issue/validating-administrative-data-detection-adverse-events-older-hospitalized-patients
March 13, 2015 - Study
Validating administrative data for the detection of adverse events in older hospitalized patients.
Citation Text:
Ackroyd-Stolarz S, Bowles SK, Giffin L. Validating administrative data for the detection of adverse events in older hospitalized patients. Drug Healthc Patient Saf. 201…
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psnet.ahrq.gov/issue/missed-rationed-or-unfinished-nursing-care-scoping-review-patient-outcomes
May 29, 2024 - Review
Missed, rationed or unfinished nursing care: a scoping review of patient outcomes.
Citation Text:
Kalánková D, Kirwan M, Bartoníčková D, et al. Missed, rationed or unfinished nursing care: A scoping review of patient outcomes. J Nurs Manag. 2020;28(8):1783-1797. doi:10.1111/jonm.1…
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psnet.ahrq.gov/issue/multi-level-analysis-national-nursing-students-disclosure-patient-safety-concerns
April 28, 2021 - Study
Multi-level analysis of national nursing students' disclosure of patient safety concerns.
Citation Text:
Palese A, Gonella S, Grassetti L, et al. Multi-level analysis of national nursing students' disclosure of patient safety concerns. Med Educ. 2018;52(11):1156-1166. doi:10.1111/m…
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psnet.ahrq.gov/issue/measuring-errors-and-adverse-events-health-care
December 30, 2014 - Study
Classic
Measuring errors and adverse events in health care.
Citation Text:
Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med. 2003;18(1). doi:10.1046/j.1525-1497.2003.20147.x.
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psnet.ahrq.gov/issue/identifying-potential-medication-discrepancies-during-medication-reconciliation-post-acute
June 17, 2020 - Study
Identifying potential medication discrepancies during medication reconciliation in the post-acute long-term care setting.
Citation Text:
Cook H, Parson J, Brandt N. Identifying Potential Medication Discrepancies During Medication Reconciliation in the Post-Acute Long-Term Care Sett…
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psnet.ahrq.gov/issue/association-patient-safety-climate-and-nurse-related-organizational-factors-selected-patient
January 22, 2014 - Study
The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey.
Citation Text:
Ausserhofer D, Schubert M, Desmedt M, et al. The association of patient safety climate and nurse-related organizational fact…
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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…
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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…
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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…
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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-…
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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.
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Goo…
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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…
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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 …
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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.…
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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.
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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…
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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…
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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…
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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…
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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…