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2241. Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - Safer Together: A National Action Plan to Advance Patient Safety was released in fall 2020. … dynamic reality, reorienting focus from performance measures of harm to measures that reflect risk prevention … to nursing homes across the United States to increase the implementation of evidence-based infection prevention … leadership, and governance—ensuring that there is a core value and non-negotiable commitment to the prevention … Aligned with our work to radically reorient our thinking and approach to safety to place more emphasis on prevention

2242. In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - dynamic reality, reorienting focus from performance measures of harm to measures that reflect risk prevention … to nursing homes across the United States to increase the implementation of evidence-based infection prevention … leadership, and governance—ensuring that there is a core value and non-negotiable commitment to the prevention … Aligned with our work to radically reorient our thinking and approach to safety to place more emphasis on prevention … Safer Together: A National Action Plan to Advance Patient Safety was released in fall 2020.

2243. A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. | PSNet
      psnet.ahrq.gov/issue/partially-structured-postoperative-handoff-protocol-improves-communication-2-mixed-surgical
      November 19, 2018 - Citation Text: Lane-Fall MB, Pascual JL, Peifer HG, et al. … Facebook Twitter Linkedin Copy URL February 6, 2019 Lane-Fall … Linkedin Copy URL Cite Citation Citation Text: Lane-Fall … December 23, 2020 Patient safety implications of wearing a face mask for prevention in

2244. The Never Antibiotics Diagnoses: Influenza and RSV – Slides
      www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/influenza-rsv-slides.pptx
      September 01, 2022 - bronchiolitis Inflammation and congestion in bronchioles RSV: Common cause of bronchiolitis Circulates in fall … Centers for Disease Control and Prevention, Influenza (Flu). … Centers for Disease Control and Prevention: Influenza (Flu). November 18, 2021.  … Centers for Disease Control and Prevention, Influenza (Flu). June 17, 2022.  … Centers for Disease Control and Prevention. Influenza.

2245. Failure to Rescue the Mother | PSNet
      psnet.ahrq.gov/web-mm/failure-rescue-mother
      September 23, 2020 - Atlanta, GA: Centers for Disease Control and Prevention. [Available at] 2. … Recognition and Prevention Transfusion of 5 units of blood in the antepartum period. … Recognition and Prevention Patient had multiple risk factors for a significant hemorrhage; it is unclear … Recognition and Prevention Response Inadequate blood products were available. … January 15, 2017 Evaluation of clinical practice guidelines on fall prevention and management

2246. Making Healthcare Safer IV_Rapid Response_Deprescribing To Reduce Medication Harms in Older Adults (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-rapid-response-deprescribing.pdf
      February 01, 2024 - 201940 9 Medication review, interdisciplinary team review; Targeted medications used for prevention … to prescriber Outpatient clinics, long- term care Age ≥65 years • no difference in falls or fall-related … Deprescribing fall- risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications … Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review

2247. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61083/psn-pdf
      October 28, 2020 - example, maybe a resident was hospitalized because they had a broken hip as a result of a preventable fall … If the fall was prevented, that broken hip wouldn't have happened and the hospitalization would have … CC: Staffing is still a big issue because nursing homes fall apart with lack of staffing.

2248. Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients. | PSNet
      psnet.ahrq.gov/issue/observational-evidence-prevalence-and-association-polypharmacy-and-drug-administration-errors
      August 11, 2021 - Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention

2249. Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers. | PSNet
      psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
      October 24, 2018 - April 30, 2014 Prevention of wrong-site tooth extraction: clinical guidelines.

2250. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60231/psn-pdf
      April 15, 2020 - Regret among primary care physicians: a survey of diagnostic decisions. April 15, 2020 Müller BS, Donner-Banzhoff N, Beyer M, et al. Regret among primary care physicians: a survey of diagnostic decisions. BMC Fam Pract. 2020;21(1). doi:10.1186/s12875-020-01125-w. https://psnet.ahrq.gov/issue/regret-among-primary-c…

2251. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
      psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
      September 01, 2011 - You wouldn't want to do a root cause analysis about a fall every time it happens. … What is it about a fall that's different than a wrong-site surgery that—assuming it was painless and

2252. Potentially inappropriate prescribing and its associations with health-related and system-related outcomes in hospitalised older adults: a systematic review and meta-analysis. | PSNet
      psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-and-its-associations-health-related-and-system-related
      July 28, 2021 - August 19, 2020 Nurses' harm prevention practices during admission of an older person

2253. Implementation of an integrated computerized prescriber order-entry system for chemotherapy in a multisite safety-net health system. | PSNet
      psnet.ahrq.gov/issue/implementation-integrated-computerized-prescriber-order-entry-system-chemotherapy-multisite
      August 30, 2023 - March 2, 2011 Effect of an emergency department process improvement package on suicide prevention

2254. Occurrence of no-harm incidents and adverse events in hospitalized patients with ischemic stroke or TIA: a cohort study using trigger tool methodology. | PSNet
      psnet.ahrq.gov/issue/occurrence-no-harm-incidents-and-adverse-events-hospitalized-patients-ischemic-stroke-or-tia
      August 05, 2020 - September 21, 2022 Artificial intelligence for identifying the prevention of medication

2255. Facilitating a safe transition from the pediatric emergency department to home with a post-discharge phone call: a quality-improvement initiative to improve patient safety. | PSNet
      psnet.ahrq.gov/issue/facilitating-safe-transition-pediatric-emergency-department-home-post-discharge-phone-call
      March 13, 2015 - April 5, 2023 Insights into the climate of safety towards the prevention of falls among … Related Resources Perspectives on Safety Suicide Prevention … Interview In Conversation with Edwin Boudreaux about Suicide Prevention

2256. Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting. | PSNet
      psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
      April 27, 2022 - Application of human factors methods to ensure appropriate infant identification and abduction prevention … Application of human factors methods to ensure appropriate infant identification and abduction prevention … Application of human factors methods to ensure appropriate infant identification and abduction prevention

2257. What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization. | PSNet
      psnet.ahrq.gov/issue/what-safety-events-are-reported-ambulatory-care-analysis-incident-reports-patient-safety
      November 24, 2021 - These results can help ambulatory care settings target safety events and develop systems-level prevention … Related Resources Perspectives on Safety Suicide Prevention … Interview In Conversation with Edwin Boudreaux about Suicide Prevention

2258. Four New York Providers Use AHRQ Medication Reconciliation Toolkit to Improve Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/ktcquips86.html
      October 01, 2014 - Four New York Providers Use AHRQ Medication Reconciliation Toolkit to Improve Care Search All Impact Case Studies November 2011 Between January and September 2010, AHRQ partnered with seven Quality Improvement Organizations (QIOs) to deliver a series of onsite learning sessions and provider support calls fo…

2259. One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. | PSNet
      psnet.ahrq.gov/issue/one-size-fits-all-mixed-methods-evaluation-impact-100-single-room-accommodation-staff-and
      July 01, 2016 - Although fall rates increased following the move, the researchers felt that based on the patterns and … May 11, 2019 A randomized trial of a multifactorial strategy to prevent serious fall

2260. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33722/psn-pdf
      December 01, 2011 - Robert Wachter, Editor, AHRQ WebM&M: What have we learned about assessment of fall risk? Ann L. … RW: What does the best fall assessment program look like? … But whenever the patient's condition changes, they should be reassessed for fall risk. … Let's shift a little bit to other proposed prevention strategies, particularly in environmental ones … But they should not receive an injury as a result of a fall.