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Showing results for "fall prevention".
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  1. Medication Handling and Compounding Errors in the Operating Room. | PSNet

    psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
    May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room. Citation Text: Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846126/psn-pdf
    March 09, 2023 - Medication Handling and Compounding Errors in the Operating Room. March 15, 2023 Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room The Case A 62-y…

  3. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet

    psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? Ashish K. Jha, MD, MPH | September 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Jha AK. What Can the Rest of the Heal…

  4. In Conversation With... Libby Hoy and Stephen Hoy | PSNet

    psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
    March 10, 2021 - engaged person in my care, I can work with my nurses so that they have good quality information about my fall … Related Resources Patient Safety Innovations Suicide Prevention

  5. Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - • In this case, the patient had none of these risk factors, so there was no missed opportunity for prevention … Prevention and management of major complications in percutaneous endoscopic gastrostomy.

  6. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet

    psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - 7,8,10,11 In this case, the patient had none of these risk factors, so there was no missed opportunity for prevention … Prevention and management of major complications in percutaneous endoscopic gastrostomy.

  7. In Conversation With… Eduardo Salas, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
    November 01, 2011 - Reducing falls and fall-related injuries in the VA system. J Healthc Saf Q. 2003;1:25-33. 8.

  8. Failed Interpretation of Screening Tool: Delayed Treatment | PSNet

    psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment Citation Text: Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citatio…

  9. Lost in Transition | PSNet

    psnet.ahrq.gov/web-mm/lost-transition
    November 17, 2010 - Catastrophe requires multiple failures—a single point failure is not enough.”( 14 ) Communication failures fall

  10. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet

    psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - provider is unavailable or distracted, creating opportunities for critical pieces of information to fall

  11. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures | PSNet

    psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
    November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures Citation Text: Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72689/psn-pdf
    January 29, 2021 - ) activation of a code or rapid response, 3) a significant change in clinical status, 4) a patient fall

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857061/psn-pdf
    November 27, 2023 - patient care learning activities in four spheres of care across the lifespan: wellness and disease prevention

  14. In Conversation With… Michelle Mello, MPhil, JD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
    July 01, 2017 - If the insurer is not on board, it's very easy for things to fall off the rails. … institutions off the sidelines of the quality improvement movement and cast them in a more central role in prevention

  15. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? | PSNet

    psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
    July 01, 2017 - institutions off the sidelines of the quality improvement movement and cast them in a more central role in prevention … If the insurer is not on board, it's very easy for things to fall off the rails.

  16. In Conversation With… Sigall K. Bell, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
    February 26, 2025 - But we still fall short.

  17. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
    January 01, 2024 - – Clinicians in these high risk, high reward situations may also fall prey to commission bias, which

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33866/psn-pdf
    September 01, 2018 - But we still fall short.

  19. In Conversation with...James P. Bagian, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
    September 01, 2006 - In Conversation with...James P. Bagian, MD September 1, 2006  Also Read an Essay Also Read an Essay Citation Text: In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…

  20. The Role of Undergraduate Nursing Education in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - patient care learning activities in four spheres of care across the lifespan: wellness and disease prevention … March 27, 2024 Perspectives on Safety Suicide Prevention … Interview In Conversation with Edwin Boudreaux about Suicide Prevention
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