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psnet.ahrq.gov/issue/mix-wrong-route-administration-bladder-irrigation-intravenous-iv-infusions
March 27, 2005 - Government Resource
Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions.
Citation Text:
Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions. Veterans Affairs; National Center for Patient Safety
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psnet.ahrq.gov/issue/nurses-role-detecting-deterioration-ward-patients-systematic-literature-review
March 27, 2018 - Review
Nurses' role in detecting deterioration in ward patients: systematic literature review.
Citation Text:
Nurses' role in detecting deterioration in ward patients: systematic literature review. Odell M; Victor C; Oliver D.
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psnet.ahrq.gov/issue/english-patient-safety-programme
September 02, 2020 - Special or Theme Issue
The English Patient Safety Programme.
Citation Text:
The English Patient Safety Programme. J Health Serv Research Policy. 2010;15(suppl 1):S1-S91.
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psnet.ahrq.gov/issue/mothers-face-broken-addiction-treatment-system
January 25, 2023 - Related Resources
‘I felt like I was dying’: how women with postpartum depression fall
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psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects-analysis
March 18, 2010 - Special or Theme Issue
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis.
Citation Text:
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis. PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50. …
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psnet.ahrq.gov/issue/medical-misdiagnoses-can-have-fatal-consequences
July 27, 2011 - Newspaper/Magazine Article
Medical misdiagnoses can have fatal consequences.
Citation Text:
Medical misdiagnoses can have fatal consequences. Olsen D. State Journal-Register. June 26, 2011.
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psnet.ahrq.gov/node/49468/psn-pdf
December 16, 2004 - The Joint Commission's Universal Protocol for the Prevention of Wrong Site, Wrong
Procedure, and Wrong … Most
systems, even simple ones, operating in health care organizations today fall short of this characterization
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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
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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
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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
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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…
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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
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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
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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…
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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
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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
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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
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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
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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
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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