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4181. Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals. | PSNet
      psnet.ahrq.gov/issue/variability-collection-and-use-raceethnicity-and-language-data-93-pediatric-hospitals
      July 15, 2020 - Study Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals. Citation Text: Cowden JD, Flores G, Chow T, et al. Variability in collection and use of race/ethnicity and language data in 93 pediatric hospitals. J Racial Ethn Health Disparities. 202…

4182. Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications. | PSNet
      psnet.ahrq.gov/issue/association-between-night-time-surgery-and-occurrence-intraoperative-adverse-events-and
      October 13, 2021 - Study Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications. Citation Text: Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications. Cortegi…

4183. Epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review. | PSNet
      psnet.ahrq.gov/issue/epidemiology-and-risk-factors-coronavirus-infection-health-care-workers-living-rapid-review
      March 02, 2011 - Review Emerging Classic Epidemiology of and risk factors for coronavirus infection in health care workers: a living rapid review. Citation Text: Chou R, Dana T, Buckley DI, et al. Epidemiology of and risk factors for coronavirus infection in health care workers:…

4184. Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis. | PSNet
      psnet.ahrq.gov/issue/exploring-changes-patient-safety-incidents-during-covid-19-pandemic-canadian-regional
      March 18, 2020 - Study Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis. Citation Text: Lombardi J, Strobel S, Pullar V, et al. Exploring changes in patient safety incidents during the COVID-19 pandemic…

4185. Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications. | PSNet
      psnet.ahrq.gov/issue/multicentre-study-develop-medication-safety-package-decreasing-inpatient-harm-omission-time
      May 18, 2022 - Study Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications. Citation Text: Graudins LV, Ingram C, Smith BT, et al. Multicentre study to develop a medication safety package for decreasing inpatient harm from omis…

4186. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. | PSNet
      psnet.ahrq.gov/issue/critical-incidents-involving-medical-emergency-team-5-year-retrospective-assessment
      November 11, 2020 - Study Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement. Citation Text: Danielis M, Destrebecq A, Terzoni S, et al. Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcar…

4187. General practitioners' risk literacy and real-world prescribing of potentially hazardous drugs: a cross-sectional study. | PSNet
      psnet.ahrq.gov/issue/general-practitioners-risk-literacy-and-real-world-prescribing-potentially-hazardous-drugs
      December 21, 2014 - Study General practitioners' risk literacy and real-world prescribing of potentially hazardous drugs: a cross-sectional study. Citation Text: Wegwarth O, Hoffmann TC, Goldacre B, et al. General practitioners’ risk literacy and real-world prescribing of potentially hazardous drugs: a cros…

4188. "Never events" and the quest to reduce preventable harm. | PSNet
      psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm
      June 01, 2016 - Commentary "Never events" and the quest to reduce preventable harm. Citation Text: Austin M, Pronovost P. "Never events" and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf. 2015;41(6):279-288. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 X…

4189. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. | PSNet
      psnet.ahrq.gov/issue/multimethod-study-large-scale-programme-improve-patient-safety-using-harm-free-care-approach
      January 23, 2019 - Study Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. Citation Text: Power M, Brewster L, Parry G, et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. BMJ Open. 2016;6(9):e0…

4190. Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic. | PSNet
      psnet.ahrq.gov/issue/unpacking-complexity-covid-19-fatalities-adverse-events-contributing-factors-single-center
      January 25, 2023 - Study Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic. Citation Text: Zińczuk A, Rorat M, Simon K, et al. Unpacking the complexity of COVID-19 fatalities: adverse event…

4191. 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…

4192. 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…

4193. 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…

4194. 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-…

4195. 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…

4196. 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.…

4197. 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…

4198. 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…

4199. 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…

4200. 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…