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4101. Using community detection techniques to identify themes in COVID-19-related patient safety event reports. | PSNet
      psnet.ahrq.gov/issue/using-community-detection-techniques-identify-themes-covid-19-related-patient-safety-event
      July 29, 2020 - Study Using community detection techniques to identify themes in COVID-19-related patient safety event reports. Citation Text: Boxley C, Krevat SA, Sengupta S, et al. Using community detection techniques to identify themes in COVID-19-related patient safety event reports. J Patient Saf. …

4102. Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study. | PSNet
      psnet.ahrq.gov/issue/strategies-safe-interhospital-transfer-intubated-patient-or-where-readiness-intubation-needed
      July 31, 2013 - Study Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study. Citation Text: Almqvist D, Norberg D, Larsson F, et al. Strategies for a safe interhospital transfer with an intubated patient or where re…

4103. Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. | PSNet
      psnet.ahrq.gov/issue/determining-skills-needed-frontline-nhs-staff-deliver-quality-improvement-findings-six-case
      March 30, 2022 - Study Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. Citation Text: Wright DJ, Gabbay J, Le May A. Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies. BM…

4104. Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study. | PSNet
      psnet.ahrq.gov/issue/engaging-patients-and-informal-caregivers-improve-safety-and-facilitate-person-and-family
      March 08, 2023 - Study Engaging patients and informal caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital to home: a qualitative descriptive study. Citation Text: Backman C, Cho-Young D. Engaging patients and informal caregivers to improve safety …

4105. Improving safety recommendations before implementation: a simulation-based event analysis to optimize interventions designed to prevent recurrence of adverse events. | PSNet
      psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event-analysis-optimize
      July 24, 2019 - Study Improving safety recommendations before implementation: a simulation-based event analysis to optimize interventions designed to prevent recurrence of adverse events. Citation Text: Langevin M, Ward N, Fitzgibbons C, et al. Improving safety recommendations before implementation: a s…

4106. Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? | PSNet
      psnet.ahrq.gov/issue/temporal-trends-patient-safety-netherlands-reductions-preventable-adverse-events-or-end
      June 30, 2021 - Commentary Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? Citation Text: Shojania KG, van de Mheen PJM-. Temporal trends in patient safety in the Netherlands: reductions in preventable advers…

4107. How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? | PSNet
      psnet.ahrq.gov/issue/how-does-workplace-violence-reporting-culture-affect-workplace-violence-nurse-burnout-and
      February 08, 2023 - Study How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? Citation Text: Kim S, Lynn MR, Baernholdt MB, et al. How does workplace violence-reporting culture affect Workplace violence, nurse burnout, and patient safety? J Nurs Care Q…

4108. Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. | PSNet
      psnet.ahrq.gov/issue/harnessing-situ-simulation-identify-human-errors-and-latent-safety-threats-adult-tracheostomy
      September 23, 2020 - Study Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. Citation Text: Hassan B, Tawfik M-M, Schiff E, et al. Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care. Jt Comm J …

4109. What is the medication iatrogenic risk in elderly outpatients for chronic pain? | PSNet
      psnet.ahrq.gov/issue/what-medication-iatrogenic-risk-elderly-outpatients-chronic-pain
      February 12, 2020 - Study What is the medication iatrogenic risk in elderly outpatients for chronic pain? Citation Text: Jambon J, Choukroun C, Roux-Marson C, et al. What is the medication iatrogenic risk in elderly outpatients for chronic pain? Clin Neuropharmacol. 2022;45(3):65-71. doi:10.1097/wnf.0000000…

4110. Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? | PSNet
      psnet.ahrq.gov/issue/rates-adverse-events-hospitalized-patients-after-summer-time-resident-changeover-united
      June 22, 2022 - Study Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect? Citation Text: Metersky ML, Eldridge N, Wang Y, et al. Rates of adverse events in hospitalized patients after summer-time resident changeover in the …

4111. The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department. | PSNet
      psnet.ahrq.gov/issue/impact-22-month-multistep-implementation-program-speaking-behavior-academic-anesthesia
      January 11, 2023 - Study The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department. Citation Text: Walther F, Schick C, Schwappach DLB, et al. The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesth…

4112. 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…

4113. 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…

4114. 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-…

4115. 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…

4116. 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.…

4117. 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…

4118. 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…

4119. 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…

4120. 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…