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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - October 11, 2023
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - In these situations, decisions for the unrepresented patient fall
to the medical provider.
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - Although infection prevention efforts have traditionally focused on preventing transmission of infection
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psnet.ahrq.gov/issue/playing-it-safe-simulated-team-training-or
July 22, 2020 - November 3, 2021
Effect of promoting high-quality staff interactions on fall prevention
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Deadly Duo
October 1, 2010
Evaluation of clinical practice guidelines on fall … prevention and management for older adults: a systematic review.
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - , also requires a prescriber to provide education to a patient and his or her designee on
overdose prevention
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - delivery. 17 Following up on pending tests or laboratory studies and informing providers of results may fall … Stopped Here
June 1, 2004
WebM&M Cases
Another Fall
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - The prevention and management of complications associated with PEG tubes in adults.
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Organizations often develop error prevention strategies following a serious event that focus solely on … The
error occurs when individuals fall victim to the flaws within the system and mistakes are made.
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care
Anita L. Tucker, DBA, MS | August 1, 2009
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Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - Combine this prevention strategy with a spirit of continuous learning from successes and failures, and … Ideally, an industry would mobilize itself to take a stand on safety and harm prevention issues.
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Centers for Disease Control and Prevention. … Centers for Disease Control and Prevention. June 11, 2024. … Centers for Disease Control and Prevention. June 28, 2024. … Centers for Disease Control and Prevention. December 13, 2023. … Medical Error Reduction and Prevention. [Updated 2024 Feb 12]. In: StatPearls [Internet].
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psnet.ahrq.gov/issue/impact-medical-mistakes-navigating-work-family-boundaries-physicians-and-their-families
January 23, 2019 - Study
Impact of medical mistakes: navigating work–family boundaries for physicians and their families.
Citation Text:
Petronio S.
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September 23, 2020 - Commentary
Clinical alarms: complexity and common sense.
Citation Text:
Phillips J.
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June 21, 2006
Phillips J.
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February 01, 2011 - June 27, 2018
Centers for Disease Control and Prevention Guideline for the Prevention … April 3, 2013
Perspective
Implementing a Fall Prevention
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - Centers for Disease Control and Prevention Web site.
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - serious adverse effects including death.( 1,19 ) In 2012, the Centers for Disease Control and Prevention … Patients with concurrent substance abuse and high risk for abusing the prescription opiates fall under … Centers for Disease Control and Prevention. … Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. … Centers for Disease Control and Prevention.
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psnet.ahrq.gov/issue/virtual-ambulatory-cusp-training
June 05, 2024 - influence of organizational context on quality improvement and patient safety efforts in infection prevention … June 15, 2022
Home health staff perspectives on infection prevention and control: implications … March 2, 2023
AHRQ Safety Program for MRSA Prevention.
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…