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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - We looked at the outcomes on falls, pressure ulcers, and restraint use. … We found that places with the worst patient safety culture scores had an association with falls and use … case mix adjust in the nursing home environment good enough that you can make sense of differences in falls
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - While falling asleep, he was noted to have eye-rolling and he did not respond to his name, shaking his … On physical exam, the patient was asleep, arousing briefly with stimulation but then falling back to … Related Resources From the Same Author(s)
WebM&M Cases
Falling
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psnet.ahrq.gov/node/45812/psn-pdf
June 22, 2017 - A primer on PDSA: executing plan–do–study–act cycles
in practice, not just in name.
June 22, 2017
Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name.
BMJ Qual Saf. 2017;26(7):572-577. doi:10.1136/bmjqs-2016-006245.
https://psnet.ahrq.gov/issue/primer-pdsa-execu…
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psnet.ahrq.gov/node/47205/psn-pdf
July 25, 2018 - Teamwork and Teamwork Training in Healthcare.
July 25, 2018
Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M,
Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527.
doi:10.1177/1059601118774669.
https://psnet.ahrq.gov/issue/teamwork-and-teamwor…
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psnet.ahrq.gov/node/74871/psn-pdf
October 01, 2023 - AHRQ Safety Program for MRSA Prevention.
February 14, 2023
Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023.
https://psnet.ahrq.gov/issue/ahrq-safety-program-mrsa-prevention
Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals. Thi…
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psnet.ahrq.gov/node/41367/psn-pdf
May 09, 2012 - harm-free-care
This initiative seeks to reduce four key sources of harm in hospitals: pressure ulcers, falls
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psnet.ahrq.gov/web-mm/collegiality-vs-competence
August 28, 2024 - May 22, 2024
Talking about falls: a qualitative exploration of spoken communication of
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psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
June 15, 2024 - Therefore, although the institution's CLABSI rates are falling, there is room for improvement. … Points falling above the upper control limit indicate months when the process was out of control.
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psnet.ahrq.gov/node/39649/psn-pdf
June 30, 2010 - https://psnet.ahrq.gov/issue/safety
https://psnet.ahrq.gov/issue/negotiating-safety-when-staffing-falls-short
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psnet.ahrq.gov/node/36584/psn-pdf
January 12, 2011 - psnet.ahrq.gov/issue/will-my-patient-fall
The authors assessed the literature to determine risk factors for falls
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psnet.ahrq.gov/issue/investigating-long-term-consequences-adverse-medical-events-among-older-adults
March 24, 2019 - September 27, 2023
Cost of inpatient falls and cost-benefit analysis of implementation … July 31, 2008
Evaluation of a patient-centered fall-prevention tool kit to reduce falls
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psnet.ahrq.gov/node/41882/psn-pdf
November 28, 2012 - design and initial test of a large-scale initiative to track incidents involving
pressure ulcers, falls
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psnet.ahrq.gov/node/35870/psn-pdf
July 23, 2010 - Platform Model as a framework for implementing patient safety initiatives
and apply the model to a falls
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psnet.ahrq.gov/node/35848/psn-pdf
July 21, 2010 - a staff-driven reporting program to collect data on indicators such
as medication errors, patient falls
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psnet.ahrq.gov/node/34632/psn-pdf
March 28, 2005 - These
include protecting patients from hospital-acquired infection, minimizing falls and confusion,
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psnet.ahrq.gov/node/38209/psn-pdf
June 02, 2010 - effects-emergency-department-staff-rounding-patient-safety-and-satisfaction
Regularly scheduled rounds by nursing staff reduced falls
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - https://psnet.ahrq.gov/issue/elephant-patient-safety-what-you-see-depends-how-you-look
incident is falls … Falls are a classic example of something that there's almost no point in reporting. … It happens often enough that we should probably approach falls almost
the way we approach infection … Falls are a common enough problem at every hospital that you
should stop doing incident reports. … Had they had a history of falls? That's a very structured type of data collection.
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psnet.ahrq.gov/issue/using-stakeholder-intervention-refinement-teams-develop-approaches-real-time-integration
January 21, 2019 - March 12, 2014
Talking about falls: a qualitative exploration of spoken communication … Strategies to improve the patient safety outcome indicator: preventing or reducing falls
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psnet.ahrq.gov/node/40311/psn-pdf
March 23, 2011 - military hospitals, greater nursing experience and skill mix was associated with a
lower incidence of falls
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psnet.ahrq.gov/node/844785/psn-pdf
September 11, 2019 - Information flow during pediatric trauma care transitions:
things falling through the cracks. … Information flow during pediatric trauma care transitions:
things falling through the cracks. … https://psnet.ahrq.gov/issue/information-flow-during-pediatric-trauma-care-transitions-things-falling-through … https://psnet.ahrq.gov/issue/information-flow-during-pediatric-trauma-care-transitions-things-falling-through-cracks … https://psnet.ahrq.gov/issue/information-flow-during-pediatric-trauma-care-transitions-things-falling-through-cracks