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2281. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
      July 01, 2023 - Tool: Check-Back (or Repeat-Back) A check-back, which is sometimes called a repeat-back, is a closed-loop communication strategy used to verify and validate exchanged information. When a team member calls out information, they typically anticipate a check-back in response to verify that the information was rece…

2282. 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

2283. 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

2284. 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

2285. 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

2286. Blood Thinner Pills: Your Guide to Using Them Safely | Agency for Healthcare Research and Quality
      www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.html
      March 01, 2023 - A serious fall or bump on the head. Dizziness or weakness. … While Taking Your Blood Thinner Call your doctor and go to the hospital immediately if you have had a fall … For example, if you fall and hit your head, bleeding can occur inside your skull. … Or, if you hurt your arm during a fall and then notice a large purple bruise, this means you are bleeding

2287. Refused Medication Error | PSNet
      psnet.ahrq.gov/web-mm/refused-medication-error
      November 01, 2005 - Throughout his admission, he was assessed as a very high fall risk on a standard risk scale. … l, the staff's level of concern was heightened, in that a fall could be associated with dangerous bleeding … alerted the primary care team of the patient's declining mental status and their concern about increased fall

2288. A Sweet Case of Hidden Hydrogen Ions | PSNet
      psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
      November 30, 2023 - The following day, she had a near fall, blurry vision, and change in mental status.  … identified by calculating the compensatory response to the primary abnormality and, when the values fall … Increasing Hospitalizations for DKA: A Need for Prevention Programs.  … Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report, 2020. … Atlanta, GA: Center for Disease Control and Prevention, U.S.

2289. Why are patients not more involved in their own safety? A questionnaire-based survey in a multi-ethnic North London hospital population. | PSNet
      psnet.ahrq.gov/issue/why-are-patients-not-more-involved-their-own-safety-questionnaire-based-survey-multi-ethnic
      September 22, 2021 - Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention

2290. Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety data from 2008 to 2011. | PSNet
      psnet.ahrq.gov/issue/has-improved-hand-hygiene-compliance-reduced-risk-hospital-acquired-infections-among
      July 10, 2024 - January 9, 2014 Health economic evaluation of an infection prevention and control program

2291. Prevalence of triggers and patient harm identified by Global Trigger Tool in specialized palliative care. | PSNet
      psnet.ahrq.gov/issue/prevalence-triggers-and-patient-harm-identified-global-trigger-tool-specialized-palliative
      June 14, 2023 - Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention

2292. Making patients safer: nurses' responses to patient safety alerts. | PSNet
      psnet.ahrq.gov/issue/making-patients-safer-nurses-responses-patient-safety-alerts
      April 13, 2011 - Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention

2293. A visual medication schedule to improve anticoagulation control: a randomized, controlled trial. | PSNet
      psnet.ahrq.gov/issue/visual-medication-schedule-improve-anticoagulation-control-randomized-controlled-trial
      October 21, 2010 - Prevention of medication errors remains a focus of patient safety efforts, with warfarin use posing

2294. Handoffs causing patient harm: a survey of medical and surgical house staff. | PSNet
      psnet.ahrq.gov/issue/handoffs-causing-patient-harm-survey-medical-and-surgical-house-staff
      July 10, 2008 - Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention

2295. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. | PSNet
      psnet.ahrq.gov/issue/ergonomic-and-human-factors-affecting-anesthetic-vigilance-and-monitoring-performance
      May 31, 2011 - December 8, 2010 Ounce of prevention: to reduce errors, hospitals prescribe innovative

2296. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet
      psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
      January 01, 2015 - Every year, Virginia Mason takes care of close to 300, mostly elderly, patients who fall and need urgent … He still had moments where he would fall back into traditional management behaviors and sometimes he … We still fall back on old habits and old behaviors, but it's starting to take a life where it would be … April 1, 2014 Perspective How Does Infection Prevention … April 1, 2013 Perspective Implementing a Fall Prevention

2297. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery | PSNet
      psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
      September 27, 2023 - Centers for Disease Control and Prevention. Published June 2022. … Pharmacists During the COVID-19 Pandemic June 29, 2020 Assessment of a wearable fall … prevention system at a Veterans Health Administration hospital. … Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall … prevention program.

2298. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50939/psn-pdf
      February 26, 2020 - Homecare safety virtual quality improvement collaboratives February 26, 2020 Miller W, Asselbergs M, Bank J, et al. Homecare safety virtual quality improvement collaboratives. Healthc Q. 2020;22(SP). doi:10.12927/hcq.2020.26042. https://psnet.ahrq.gov/issue/homecare-safety-virtual-quality-improvement-collaborative…

2299. Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system. | PSNet
      psnet.ahrq.gov/issue/impact-pharmacist-led-admission-medication-reconciliation-patient-outcomes-large-health
      March 17, 2010 - April 24, 2018 Universal protection: operationalizing infection prevention guidance in … Impact of pharmacist-led discharge medication reconciliation on error and patient harm prevention

2300. 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.