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4361. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
      December 01, 2017 - operational event or situation that you would not want to happen again—an unsafe condition, a patient fall

4362. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840175/psn-pdf
      November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. November 16, 2022 Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism The Case A 61-year-old woman presented to …

4363. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33660/psn-pdf
      December 01, 2007 - know health care delivery backwards and forwards—are themselves not immune from seeing these issues fall

4364. Missing Trauma | PSNet
      psnet.ahrq.gov/web-mm/missing-trauma
      March 03, 2011 - probably tops this list, followed closely by missing a transient neurologic event that precipitates a fall

4365. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33721/psn-pdf
      November 01, 2011 - Reducing falls and fall-related injuries in the VA system. J Healthc Saf Q. 2003;1:25-33. 8.

4366. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74252/psn-pdf
      January 12, 2022 - They had been a common strategy for fall prevention, but with the requirement to put on PPE, there was … a delay before a staff person could respond to the alarm and prevent a fall.

4367. July Teleconference Transcript (pdf file)
      digital.ahrq.gov/sites/default/files/docs/July%20Teleconference%20Transcript.pdf
      June 16, 2021 - So we look for evidence of a fall severe enough AHRQ 7/13/10 Page 5 to warrant a radiological

4368. Dementia-Nursing-Home-Characteristics Executive (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/dementia-nursing-home-characteristics_executive.pdf
      October 01, 2012 - 1 Comparative Effectiveness Review Number 79 Comparison of Characteristics of Nursing Homes and Other Residential Long-Term Care Settings for People With Dementia Executive Summary Background Dementia is a group of neurological conditions that lead to gradual decline in mental function. It is the most com…

4369. A Sweet Case of Hidden Hydrogen Ions | PSNet
      psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
      November 30, 2023 - The following day, she had a near fall, blurry vision, and change in mental status.  … identified by calculating the compensatory response to the primary abnormality and, when the values fall

4370. Strategy 3: Nurse Bedside Shift Report Implementation Handbook (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/Strat3_Implement_Hndbook_508.docx
      August 01, 2010 - patient falls during change of shift, dropping from one to two patient falls per month to one patient fall

4371. How CUSP Enables Nurse Empowerment (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/empowerment.html
      April 01, 2013 - I know we had implemented a couple years ago, every time a patient falls, we do a post-fall huddle. … And now we’re incorporating that learn from defects tool as the framework for those post-fall huddles … offer assistance if anybody’s assignment’s too heavy or needs some help, anybody that’s at safety risk, fall … You can see under the critical communications they identified patients that were at fall risk, that had

4372. home-based-care-protocol-141119 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/home-based-care_research-protocol.pdf
      November 19, 2014 - Single condition care or single topic risk assessments Fall risk assessments, programs that target … frequency of home visits, hours of availability) or services that could be provided separately, such as fall … of excluded care; preventive home visits, single visit home assessments, single purpose visits (fall

4373. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
      September 01, 2017 - Report data help identify residents with new ADL decline, fall risk, or fall injury, therefore at risk … Huddle for Nurse and Rehab  Managers Weekly huddle to review residents at risk for ADL decline or fall … or with fall injury and in potential need of therapy. … Discharge diagnoses were dehydration, fall with injury, cellulitis, and angina.

4374. Kidney-Disease-Medicine Surveillance (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/kidney-disease-medicine_surveillance.pdf
      October 01, 2012 - An acute fall in estimated glomerular filtration rate during treatment 21 with losartan … diabetes Change in GFR 39 months Patients assigned to losartan had a significantly greater acute fall … Patients with a large initial fall in eGFR had a significantly lower long- term eGFR slope compared … to those with a moderate fall or rise. … Thus, the greater the acute fall in eGFR during losartan treatment, the slower the rate of long-term

4375. Improving Patient Safety in Long-Term Care Facilities, Module 2 (pdf file)
      www.ahrq.gov/sites/default/files/publications/files/ltcmodule2.pdf
      June 01, 2012 - may use different words to say the same thing (e.g., new words come into general usage, while others fall … may use different words to say the same thing (e.g., new words come into general usage, while others fall

4376. Module 1. Detecting Change in a Resident's Condition | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1.html
      March 01, 2018 - Improving Patient Safety in Long-Term Care Facilities Module 1. Detecting Change in a Resident's Condition Previous Page Next Page Table of Contents Improving Patient Safety in Long-Term Care Facilities Introduction Module 1. Detecting Change in a Resident's Condition Module 2. Communicating C…

4377. Strategy 3: Bedside Shift Report (Tool 3)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
      July 23, 2010 - patient falls during change of shift, dropping from one to two patient falls per month to one patient fall … initial nursing assessment, the nurse noticed a large bruise on his elbow and hip related to a recent fall

4378. Final Progress Report: A Pilot Study for Intrgrating Facility Information With Healthcare Information to Improve Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
      January 01, 2024 - be plugged in at a certain area around the bed of a patient, the standard electrical requirements fall … Exposure_Patient -Exposure_Provider Failures - 1..* -Linked To 1..* (from AHRQ Common Formats) Fall … Only sub-classes of Fall Events, HAI Event, and Other Event are included, because they are the only

4379. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
      February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Vogus T, Lee M, Mos…

4380. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
      February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Ci…