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psnet.ahrq.gov/issue/disruptive-orthopaedic-surgeon-implications-patient-safety-and-malpractice-liability
August 20, 2018 - June 28, 2017
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/functional-health-literacy-and-understanding-medications-discharge
April 24, 2018 - February 7, 2024
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/disclosure-patient-safety-incidents-comprehensive-review
November 10, 2010 - May 18, 2022
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/sued-misdiagnosis-it-could-happen-you
February 07, 2024 - Commentary
Sued for misdiagnosis? It could happen to you.
Citation Text:
Lippman H, Davenport J. Sued for misdiagnosis? It could happen to you. J Fam Pract. 2010;59(9):498-508.
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psnet.ahrq.gov/issue/patients-role-patient-safety
May 01, 2024 - Review
The patient's role in patient safety.
Citation Text:
Corina I, Abram M, Halperin D. The patient's role in patient safety. Obstet Gynecol Clin North Am. 2019;46(2):215-225. doi:10.1016/j.ogc.2019.01.004.
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psnet.ahrq.gov/issue/six-things-every-plastic-surgeon-needs-know-about-teamwork-training-and-checklists
September 07, 2016 - September 24, 2008
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/medication-safety-just-label-away
August 18, 2021 - Commentary
Medication safety: just a label away.
Citation Text:
Jennings J, Foster J. Medication safety: just a label away. AORN J. 2007;86(4):618-25.
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Dow…
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psnet.ahrq.gov/issue/impact-pharmacists-participation-hospitalists-rounds
March 16, 2022 - Study
The impact of a pharmacist's participation on hospitalists' rounds.
Citation Text:
Patel R, Butler K, Garrett D, et al. The Impact of a Pharmacist's Participation on Hospitalists' Rounds. Hosp Pharm. 2010;45(2). doi:10.1310/hpj4502-129.
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psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-healthcare-safety-engaging-patients
March 22, 2024 - December 21, 2022
NPSD Data Spotlight: Patterns of Fall Interventions.
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psnet.ahrq.gov/issue/nursing-2006-patient-safety-survey-report
March 01, 2023 - Study
Nursing 2006 Patient-safety survey report.
Citation Text:
Manno M, Hogan P, Heberlein V, et al. Nursing 2006. Patient-safety survey report. Nursing (Brux). 2006;36(5):54-64.
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psnet.ahrq.gov/issue/tell-truth-ethical-and-practical-issues-disclosing-medical-mistakes-patients
April 19, 2011 - April 19, 2011
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
March 04, 2020 - September 20, 2023
A randomized trial of a multifactorial strategy to prevent serious fall
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hcup-us.ahrq.gov/reports/statbriefs/sb255-Traumatic-Brain-Injury-Hospitalizations-ED-Visits-2017.pdf
January 01, 2017 - groups greater than or equal to 10 percent are noted in the text.
1 Centers for Disease Control and Prevention … 79.9
0
20
40
60
80
100
Pe
rc
en
ta
ge
o
f
St
ay
s
or
V
is
its
b
Unintentional, fall … 25,200 11.2 10.3
None 5.9 16,400 4.3 13.5
Intent and mechanism of injury
Unintentional, fall … of injury matrix for
causes other than poisoning developed by the Centers for Disease Control and Prevention … vehicle-nontraffic
o Pedal cyclist, other
o Pedestrian, other
10 Centers for Disease Control and Prevention
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan29/diet-behavioral-counseling-primary-care-adults-2003
February 03, 2014 - providing controlled diets
Counseling interventions aimed at weight loss or weight maintenance, falls prevention … , depression, cognitive functioning, or disease prevention other than CVD/diabetes mellitus
Prenatal
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Connelly.pdf
January 01, 2003 - high-reliability organizations, risk is readily
acknowledged, error reporting is rewarded, and injury prevention … Lucian Leape on the causes and
prevention of errors and adverse events in health care.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-slides.pptx
November 01, 2016 - On-Time Overview
5
5
On-Time Reports for Four
Adverse Events
Available Reports:
Pressure Ulcer Prevention … Pressure Ulcer Healing
Reports in Development:
Falls Prevention
Prevention of Avoidable Hospitalizations … feasibility and ease of use
Large decline in pressure ulcer incidence rate seen in Pressure Ulcer Prevention
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-6-slides.pdf
October 28, 2021 - .1
Learn more about AHRQ’s Framework for Care Coordination at
https://www.ahrq.gov/professionals/prevention-chronic … Workflow Processes
Identify what is working and what is not
• Where do patients fall
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www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-a.html
June 01, 2020 - 362
181
157
14
10
92%
0.55
Pediatrics
362
181
175
1
5
99%
0.91
Prevention … 93%
61%
96%
0.57
Pediatrics
2,459
69
2,348
21
21
98%
77%
99%
0.76
Prevention … less accurate for a particular category; (3) the results include fewer project abstracts that clearly fall … inside or outside a category and more abstracts that appear to fall somewhere in between. … )
1–1
1,308
(19%)
1,194–1,421
0(0%)
0–0
1,457
(16%)
1,335–1,578
Prevention
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - National Action Plan for Adverse Drug Event Prevention. … Washington, DC: Office of Disease Prevention
and Health Promotion, United States Department of Health
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psnet.ahrq.gov/perspective/accountability-patient-safety
January 01, 2018 - patients believe clinicians should be held accountable for basic safety practices, such as hand hygiene, fall … Nevertheless, the scope of behaviors that fall under individual accountability is still controversial