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4061. Strategies and Approaches for Tracking Improvements in Patient Safety | PSNet
      psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
      June 15, 2024 - Strategies and Approaches for Tracking Improvements in Patient Safety Citation Text: Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citat…

4062. Discussion | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/pfp/haccost2017-discuss.html
      November 01, 2017 - Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions Discussion Previous Page Next Page Table of Contents Estimating the Additional Hospital Inpatient Cost and Mortality Associated With Selected Hospital-Acquired Conditions Discussio…

4063. Sustaining Zero CLABSIs | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/zero-clabsi/slides.html
      July 01, 2013 - for unstable ambulatory patients Stretcher-locking mechanism failure noted and prevented patient fall

4064. Jun-2017-Cholesterol-Wg-Notes (doc file)
      cds.ahrq.gov/sites/default/files/workgroups/241/jun-2017-cholesterol-wg-notes.docx
      January 01, 2017 - this population do not take in to account scenarios where patients who are well controlled on statins fall

4065. Section 3: Teaching the Key Concepts and Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/team/teach/index.html
      August 01, 2023 - A new version of the app will be available in fall 2023.

4066. Section 3: Teaching the Key Concepts and Tools | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/situation/teach/index.html
      August 01, 2023 - A new version of the app will be available in fall 2023.

4067. Section 3: Teaching Mutual Support Key Concepts and Tools  | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/mutual/teach/index.html
      August 01, 2023 - A new version of the app will be available in fall 2023.

4068. The impact of rudeness on medical team performance: a randomized trial. | PSNet
      psnet.ahrq.gov/issue/impact-rudeness-medical-team-performance-randomized-trial
      April 24, 2018 - Study Classic The impact of rudeness on medical team performance: a randomized trial. Citation Text: Riskin A, Erez A, Foulk T, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015;136(3):487-495. doi:10.1542/peds.2015-…

4069. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. | PSNet
      psnet.ahrq.gov/issue/defining-identifying-and-addressing-problematic-polypharmacy-within-multimorbidity-primary
      July 22, 2015 - Review Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review. Citation Text: Tsang JY, Sperrin M, Blakeman T, et al. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scop…

4070. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. | PSNet
      psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-events-among-older-persons-ambulatory-setting
      March 11, 2011 - Study Classic Incidence and preventability of adverse drug events among older persons in the ambulatory setting. Citation Text: Gurwitz JH, Field T, Harrold LR, et al. Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Se…

4071. Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. | PSNet
      psnet.ahrq.gov/issue/observational-evidence-prevalence-and-association-polypharmacy-and-drug-administration-errors
      August 11, 2021 - Study Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. Citation Text: Savva G, Papastavrou E, Charalambous A, et al. Observational evidence of the prevalence and association of polypharmacy and drug ad…

4072. 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…

4073. 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…

4074. 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-…

4075. 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…

4076. 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.…

4077. 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…

4078. 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…

4079. 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…

4080. 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…