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psnet.ahrq.gov/issue/nhs-safety-thermometer-report-patient-harms-and-harm-free-care-november-2014-november-2015
July 08, 2021 - Book/Report
NHS Safety Thermometer Reports.
Citation Text:
NHS Safety Thermometer Reports. Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. 2012-2017.
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psnet.ahrq.gov/issue/findings-and-lessons-improving-quality-through-clinician-use-health-it-grant-initiative
November 21, 2016 - Government Resource
Findings and Lessons From the Improving Quality Through Clinician Use of Health IT Grant Initiative.
Citation Text:
Findings and Lessons From the Improving Quality Through Clinician Use of Health IT Grant Initiative. Rockville, MD: Agency for Healthcare Research…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - specific written protocol, certain medical
information can be assumed because the patient observations fall … Hospitals and
clinicians should be cautious of quick fixes or reliance on a single prevention technique
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - The unit where the fall occurred called a multidisciplinary "fall huddle" to reenact the circumstances
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psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
March 01, 2009 - He noted that the diphenhydramine made him somewhat drowsy, but not enough to fall asleep. … Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34.
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - male with a history of chronic opioid use, anxiety disorder, and major depression
presented after a fall … specifically,
post-operative pain management encompasses a balance of adequate pain control and the prevention … Points
Implementing standardized sedation assessments, such as POSS, aids nurses in the prediction and
prevention
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Reducing falls and fall-related injuries in the VA system. J Healthc Saf Q. 2003;1:25-33.
8. … January 1, 2015
Perspective
How Does Infection Prevention … February 1, 2014
Perspective
Implementing a Fall … Prevention Program
December 1, 2011
Medical Errors and Safety Systems.
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - How to Monitor Patients
Receiving Direct Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Prevention of Adverse Drug Events
https://psnet.ahrq.gov/issue/preventing-medication-errors-quality-chasm-series … Safety Goal for both hospitals and ambulatory clinics, and the
Partnership for Patients included ADE prevention … The Office of Disease
Prevention and Health Promotion issued the National Action Plan for Adverse Drug … Event Prevention in
2014, which identified ways to align the efforts of federal health agencies to
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - know health care delivery backwards and forwards—are themselves not immune from seeing these issues fall … Interview
In Conversation with Edwin Boudreaux about Suicide Prevention … Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/node/33589/psn-pdf
September 15, 2024 - High Reliability
September 15, 2024
High Reliability. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/high-reliability
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Lucian Leape highlighted the issue and presented a framework for
error analysis and prevention that … include:
Preventable adverse events: those due to error or failure to apply an accepted strategy for
prevention
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psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations-translation-practice
February 17, 2015 - April 25, 2016
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/speaking-constructively-managerial-practices-elicit-solutions-front-line-employees
September 05, 2012 - Book/Report
Speaking Up Constructively: Managerial Practices that Elicit Solutions from Front-Line Employees.
Citation Text:
Speaking Up Constructively: Managerial Practices that Elicit Solutions from Front-Line Employees. Adler-Milstein JR, Singer SJ, Toffel MW. Cambridge, MA: Harva…
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psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting
May 20, 2009 - The most common adverse events reported were pressure ulcers and fall-related injuries or deaths .
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psnet.ahrq.gov/issue/attending-work-hour-restrictions-it-time
November 28, 2012 - November 28, 2012
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/learning-and-sharing-safety-lessons-improve-patient-care
August 07, 2019 - Commentary
Learning and sharing safety lessons to improve patient care.
Citation Text:
Woodward S. Learning and sharing safety lessons to improve patient care. Nursing Standard. 2016;20(18). doi:10.7748/ns.20.18.49.s52.
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DOI Google Scholar BibTeX EndNot…
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psnet.ahrq.gov/issue/opioids-pain-management-older-adults-strategies-safe-prescribing
January 26, 2022 - Use of opioids for pain management in older adults can contribute to various problems, including fall-related
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psnet.ahrq.gov/issue/disclosure-medical-errors-right-thing-do
September 13, 2010 - July 22, 2010
WebM&M Cases
Another Fall
April 1,