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psnet.ahrq.gov/node/37792/psn-pdf
February 15, 2011 - Exploring organizational context and structure as
predictors of medication errors and patient falls.
February 15, 2011
Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of
Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e3181695671.…
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psnet.ahrq.gov/issue/iatrogenic-delirium-and-coma-near-miss
September 23, 2020 - May 27, 2011
Effect of computer order entry on prevention of serious medication errors … May 26, 2011
Centers for Disease Control and Prevention Guideline for the Prevention … November 16, 2022
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/node/44932/psn-pdf
March 02, 2016 - in this special issue explore
falls in rehabilitation settings, including nurses' role in managing fall … exploring-health-care-professionals-perceptions-incidents-and-incident-reporting
https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - , hemodynamic shifts can lead to transient hypotension (low blood pressure) and dizziness.( 4 ) The fall … risk in hemodialysis patients is higher than in the general population.( 4 ) Assessment of fall risk … 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 units
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psnet.ahrq.gov/periodic-issue/periodic-issue-459
October 30, 2024 - The intervention included enhanced communication with families and staff about fall risks, physical therapy … Centers for Disease Control and Prevention . … The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults … ), appropriate use of fall assessment and prevention strategies, and strategies to improve communication
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psnet.ahrq.gov/issue/deep-scope-framework-safe-healthcare-design
August 18, 2021 - August 18, 2021
Artificial intelligence for identifying the prevention of medication … Innovations
Preventing Falls Through Patient and Family Engagement to Create Customized Prevention … Article
Study
The Stoplight Mobility Alert System for safety and prevention
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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
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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/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/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.
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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
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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/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/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/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/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/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