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psnet.ahrq.gov/issue/triad-xii-are-patients-aware-and-agree-dnr-or-polst-orders-their-medical-records
September 15, 2021 - Study
TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records.
Citation Text:
Mirarchi FL, Juhasz K, Cooney TE, et al. TRIAD XII: Are Patients Aware of and Agree With DNR or POLST Orders in Their Medical Records. J Patient Saf. 2019;15(3):230-237. doi…
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psnet.ahrq.gov/issue/expressing-concern-and-writing-it-down-experimental-study-investigating-transfer-information
November 17, 2014 - Study
Expressing concern and writing it down: an experimental study investigating transfer of information at nursing handover.
Citation Text:
Lee H, Cumin D, Devcich DA, et al. Expressing concern and writing it down: an experimental study investigating transfer of information at nursing …
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psnet.ahrq.gov/issue/anaesthesia-clinicians-perception-safety-workload-anxiety-and-stress-remote-hybrid-suite
March 20, 2024 - Study
Anaesthesia clinicians' perception of safety, workload, anxiety, and stress in a remote hybrid suite compared with the operating room.
Citation Text:
Schroeck H, Whitty MA, Martinez-Camblor P, et al. Anaesthesia clinicians' perception of safety, workload, anxiety, and stress in a r…
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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…
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psnet.ahrq.gov/node/851196/psn-pdf
July 05, 2023 - Patient falls while under supervision: trends from incident
reporting.
July 5, 2023
Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs.
2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508.
https://psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-…
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psnet.ahrq.gov/node/866280/psn-pdf
July 10, 2024 - Visitor restrictions during the COVID-19 pandemic and
increased falls with harm at a Canadian hospital: an
exploratory study.
July 10, 2024
Shennan S, Coyle N, Lockwood B, et al. Visitor restrictions during the COVID-19 pandemic and increased
falls with harm at a Canadian hospital: an exploratory study. J Patient …
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psnet.ahrq.gov/node/38748/psn-pdf
April 19, 2011 - Utilization of the Seniors Falls Investigation Methodology
to identify system-wide causes of falls in community-
dwelling seniors.
April 19, 2011
Zecevic AA, Salmoni AW, Lewko JH, et al. Utilization of the Seniors Falls Investigation Methodology to
identify system-wide causes of falls in community-dwelling seniors…
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psnet.ahrq.gov/node/41112/psn-pdf
February 01, 2012 - Utilizing quality improvement methods to prevent falls
and injury from falls: enhancing resident safety in long-
term care.
February 1, 2012
MacLaurin A, McConnell H. Utilizing quality improvement methods to prevent falls and injury from falls:
enhancing resident safety in long-term care. J Safety Res. 2011;42(6):…
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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…
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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…
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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.
Copy…
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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/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/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/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/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/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/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…