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2381. 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 - August 31, 2022 Improving hospital safety culture for falls prevention through interdisciplinary

2382. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? | PSNet
      psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and
      June 16, 2021 - influence of organizational context on quality improvement and patient safety efforts in infection prevention

2383. Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. | PSNet
      psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
      January 17, 2012 - September 18, 2019 Root cause analysis and actions for the prevention of medical errors

2384. Patient Safety in Frail Older Patients | PSNet
      psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
      November 26, 2019 - This makes it necessary to have patient safety practices directed specifically at prevention in these … Whereas, working on mobility, delirium prevention, skin care, etc. is a more horizontal cross-cutting … In the health system I’m at right now, we’re increasingly marrying our falls prevention work with our … Our prior approach to falls was, “if we keep them in bed they won’t fall.” … We placed fall prevention above safe mobility.

2385. In Conversation With... Heidi Wald, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-heidi-wald-md
      November 26, 2019 - Whereas, working on mobility, delirium prevention, skin care, etc. is a more horizontal cross-cutting … In the health system I’m at right now, we’re increasingly marrying our falls prevention work with our … Our prior approach to falls was, “if we keep them in bed they won’t fall.” … We placed fall prevention above safe mobility. … This makes it necessary to have patient safety practices directed specifically at prevention in these

2386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46009/psn-pdf
      September 13, 2017 - mixed methods study of 11 health services across Victoria, Australia, found that skin integrity and fall … long-term-outcomes-medication-intervention-using-screening-tool-older-persons-potentially https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities

2387. Periodic Issue | PSNet
      psnet.ahrq.gov/periodic-issue/periodic-issue-397
      June 28, 2023 - Patient fall rates can be impacted by numerous factors, such as staffing, safety culture, and individual … Additionally, good collaboration between nurses, physicians, and pharmacists was associated with lower fall … Patient fall rates can be impacted by numerous factors, such as staffing, safety culture, and individual … Additionally, good collaboration between nurses, physicians, and pharmacists was associated with lower fall … for prevention in systems, and workforce education and development.

2388. Association of overlapping cardiac surgery with short-term patient outcomes. | PSNet
      psnet.ahrq.gov/issue/association-overlapping-cardiac-surgery-short-term-patient-outcomes
      November 09, 2022 - May 12, 2021 A randomized trial of a multifactorial strategy to prevent serious fall … October 19, 2022 Evaluating the prevalence of four recommended practices for suicide prevention … Shared understanding of resilient practices in the context of inpatient suicide prevention … August 17, 2022 Development and implementation of a suicide prevention checklist to create

2389. Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. | PSNet
      psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool
      June 19, 2024 - Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention

2390. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35572/psn-pdf
      February 03, 2011 - in patient safety programs, drug administration and safety procedures, error reporting processes, prevention … However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate

2391. 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…

2392. Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens. | PSNet
      psnet.ahrq.gov/issue/partnered-pharmacist-charting-admission-general-medical-and-emergency-short-stay-unit-cluster
      July 06, 2011 - potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention … May 28, 2015 A randomized trial of a multifactorial strategy to prevent serious fall … : Topics in Medication Safety March 31, 2022 6-PACK programme to decrease fall

2393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44388/psn-pdf
      October 14, 2015 - generally seeing patients with lower acuity levels, whereas the authors speculate that the increased fall

2394. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844785/psn-pdf
      September 11, 2019 - Information flow during pediatric trauma care transitions: things falling through the cracks. September 11, 2019 Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Information flow during pediatric trauma care transitions: things falling through the cracks. Intern Emerg Med. 2019;14(5):797-805. doi:10.1007/s11739-019-0…

2395. The Safety and Quality of Long Term Care | PSNet
      psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
      January 01, 2016 - She was found to have a left hip fracture as a result of the fall and underwent an uncomplicated surgical … Home Care Contributing to Adverse Events While it is difficult to know whether the patient's initial fall … report might have alerted staff about the resident's increased pressure ulcer risk so that aggressive prevention … In the current case, perhaps frontline caregivers would have spoken up about fall risk or pressure ulcer … Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention

2396. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44872/psn-pdf
      February 12, 2016 - https://psnet.ahrq.gov/issue/partnership-patients https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities

2397. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41985/psn-pdf
      October 26, 2016 - The most common adverse events reported were pressure ulcers and fall- related injuries or deaths. … /serious-reportable-events-healthcare-2011-update https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities … https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities

2398. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49609/psn-pdf
      October 01, 2010 - risk in hemodialysis patients is higher than in the general population.(4) Assessment of fall risk, … use of neuropsychiatric medications, and avoiding hypotension in dialysis patients may all reduce fall … mandated by CMS under Medicare's conditions for coverage.(9) Future investigation into the occurrence and prevention … Falls and fall-related injuries in older dialysis patients. … Centers for Disease Control and Prevention (CDC) Sets standards for infection control in dialysis

2399. Selling soap. | PSNet
      psnet.ahrq.gov/issue/selling-soap
      March 06, 2005 - January 13, 2021 Improving hospital safety culture for falls prevention through interdisciplinary … Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention … Plans May 31, 2023 Impact of patient safety climate on infection prevention

2400. Environmental changes increase hospital safety for dementia patients. | PSNet
      psnet.ahrq.gov/issue/environmental-changes-increase-hospital-safety-dementia-patients
      January 10, 2011 - Related Resources Patient Safety Innovations Suicide Prevention … Emergency Department Population: ED-SAFE April 24, 2024 Systems approach to suicide prevention … December 2, 2015 Reducing falls and fall-related injuries in mental health: a 1-year