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441. A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center. | PSNet
     psnet.ahrq.gov/issue/quality-initiative-decrease-pathology-specimen-labeling-errors-using-radiofrequency
     August 28, 2017 - May 18, 2022 Evaluation of clinical practice guidelines on fall prevention and management … Talking about falls: a qualitative exploration of spoken communication of patients' fall … risks in hospitals and implications for multifactorial approaches to fall prevention.

442. Learning and Performance Objectives | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3obj.html
     October 01, 2014 - Module 3: Falls Prevention and Management Learning and Performance Objectives Previous Page Next Page Table of Contents Module 3: Falls Prevention and Management Learning and Performance Objectives Session 1 Session 2 Conclusion Appendix. Additional Tools and Resources Know…

443. Innovative approaches to analysing aged care falls incident data: International Classification for Patient Safety and correspondence analysis. | PSNet
     psnet.ahrq.gov/issue/innovative-approaches-analysing-aged-care-falls-incident-data-international-classification
     January 18, 2023 - March 24, 2021 Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program … to engage older adults in fall prevention in a nursing home.

444. Feasibility/Pilot Study | Digital Healthcare Research
     digital.ahrq.gov/research-method/feasibilitypilot-study
     January 01, 2025 - Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall … Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall Assessment and Prevention … Project Name Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall

445. Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study. | PSNet
     psnet.ahrq.gov/issue/developing-standard-handoff-process-operating-room-icu-transitions-multidisciplinary
     February 06, 2019 - Citation Text: Lane-Fall MB, Pascual JL, Massa S, et al. … Facebook Twitter Linkedin Copy URL November 19, 2018 Lane-Fall … Linkedin Copy URL Cite Citation Citation Text: Lane-Fall

446. Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety. | PSNet
     psnet.ahrq.gov/issue/demonstrating-value-postgraduate-fellowships-physicians-quality-improvement-and-patient
     November 04, 2015 - Citation Text: Myers JS, Lane-Fall MB, Perfetti AR, et al. … Facebook Twitter Linkedin Copy URL January 15, 2020 Myers JS, Lane-Fall … Copy URL Cite Citation Citation Text: Myers JS, Lane-Fall

447. ICU attending handoff practices: results from a national survey of academic intensivists. | PSNet
     psnet.ahrq.gov/issue/icu-attending-handoff-practices-results-national-survey-academic-intensivists
     February 06, 2019 - Citation Text: Lane-Fall MB, Collard ML, Turnbull AE, et al. … Share Facebook Twitter Linkedin Copy URL March 15, 2016 Lane-Fall … Linkedin Copy URL Cite Citation Citation Text: Lane-Fall

448. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73214/psn-pdf
     May 05, 2021 - patient-and-physician-perspectives-deprescribing-potentially-inappropriate-medications-older https://psnet.ahrq.gov/issue/modification-potentially-inappropriate-prescribing-following-fall-related-hospitalizations

449. Medication Safety Certificate Program. | PSNet
     psnet.ahrq.gov/issue/medication-safety-certificate-program
     September 30, 2020 - April 7, 2021 - April 7, 2021 Selected medication safety risks that can easily fall … August 20, 2018 Fall Prevention in Hospitals Training Program.

450. Using stakeholder intervention refinement teams to develop approaches for real-time integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions. | PSNet
     psnet.ahrq.gov/issue/using-stakeholder-intervention-refinement-teams-develop-approaches-real-time-integration
     January 21, 2019 - August 31, 2016 Evaluation of clinical practice guidelines on fall prevention and management … Talking about falls: a qualitative exploration of spoken communication of patients' fall … risks in hospitals and implications for multifactorial approaches to fall prevention.

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40146/psn-pdf
     March 02, 2011 - patient-education-prevent-falls-among-older-hospital-inpatients-randomized-controlled-trial https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial

452. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
     October 01, 2010 - Falls and fall-related injuries in older dialysis patients. … * Falls at Dialysis Centers Falls are common–nearly 50% of patients had a fall in 190.5 person-years … Falls and fall-related injuries in older dialysis patients. Clin J Am Soc Nephrol. 2006;1:1197-1204. … Preventing Falls There have been multiple recommendations to prevent falls at dialysis centers: Assess fall … Falls and fall-related injuries in older dialysis patients. Clin J Am Soc Nephrol. 2006;1:1197-1204.

453. A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. | PSNet
     psnet.ahrq.gov/issue/partially-structured-postoperative-handoff-protocol-improves-communication-2-mixed-surgical
     November 19, 2018 - Citation Text: Lane-Fall MB, Pascual JL, Peifer HG, et al. … Facebook Twitter Linkedin Copy URL February 6, 2019 Lane-Fall … Linkedin Copy URL Cite Citation Citation Text: Lane-Fall

454. Delilberative-Methods-Design-Carman (pdf file)
     effectivehealthcare.ahrq.gov/sites/default/files/delilberative-methods-design-carman.pdf
     June 01, 2012 - Slide 35 Next steps and information to look for  Next steps o Implement experiment: summer – fall … AcademyHealth Annual Research Meeting, June 2012 o Report of findings from experiment, late summer/fall

455. Task Force Issues Final Recommendation Statement on Interventions to Prevent Falls in Older Adults Exercise can reduce the likelihood of falls in adults 65 and older; additional interventions might be helpful for some older adults (pdf file)
     www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/falls-prevention-older-adults-final-rec-bulletin.pdf
     June 04, 2024 - When determining who is more likely to fall, clinicians should consider age and history of falling, as … Other risk factors include sensory problems, medications that may increase fall risk, hazards at home

456. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/impguide.html
     November 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Implementation of the Falls Prevention Reports Note: This part of the training consists of interactive exercises and does not have any slides. If you are not part of a formal training, please read all these materials, prin…

457. Task Force Issues Draft Recommendation Statement on Interventions to Prevent Falls in Older Adults (pdf file)
     www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/falls-prevention-older-adults-draft-rec-bulletin.pdf
     January 08, 2024 - When determining who is more likely to fall, clinicians should consider age and history of falling as … Other risk factors include sensory problems, medications that may increase fall risk, hazards at home

458. Generic Dashboard Data 2025 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2025.xlsx
     January 01, 2025 - Introduction Introduction - Generic Patient Safety Concern   The tables in this workbook present generic data on Patient Safety Concerns submitted by AHRQ-listed Patient Safety Organizations (PSOs) to the Network of Patient Safety Databases (NPSD) through December 31, 2024. The tables include distributions of events…

459. Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category (pdf file)
     pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
     January 01, 2019 - changes in mental status • Cascade with oversedation while on multiple opioid medications leading to a fall … patient resulting in desaturation, hypoxemia, replacement of the tube, and aspiration pneumonia Fall … with injury • Fall with recurrent right hip fracture associated with inadequate monitoring Page 5 … from gastric secretions due to PEG leak • Skin tear and abrasion on sacral area • Skin tear forearm Fall … with injury • Fall with laceration forehead • Fall with soft tissue hematoma over left maxillary sinus

460. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39460/psn-pdf
     March 23, 2011 - and used the findings to design a quality improvement intervention that significantly reduced the fall