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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - Patients are at risk of falls. … The "solution" is an
assessment form and an action plan related to the risk of 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/867139/psn-pdf
November 13, 2024 - Workplace violence pervasiveness in the perioperative
environment: a multiprofessional survey.
November 13, 2024
Lin DM, Lane-Fall MB, Lea JA, et al. Workplace violence pervasiveness in the perioperative environment: a
multiprofessional survey. Jt Comm J Qual Patient Saf. 2024;50(11):764-774.
doi:10.1016/j.jcjq.20…
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psnet.ahrq.gov/node/836959/psn-pdf
April 20, 2022 - Safety of elderly fallers: identifying associated risk
factors for 30-day unplanned readmissions using a
clinical data warehouse.
April 20, 2022
El Abd A, Schwab C, Clementz A, et al. Safety of elderly fallers: identifying associated risk factors for 30-
day unplanned readmissions using a clinical data warehouse. …
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psnet.ahrq.gov/node/34732/psn-pdf
May 09, 2015 - A Tale of Two Stories: Contrasting Views of Patient
Safety.
May 9, 2015
Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997.
https://psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
A report from a workshop, this document is a well-written look at the difference…
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psnet.ahrq.gov/node/865872/psn-pdf
May 15, 2024 - Speaking up and taking action: psychological safety and
joint problem-solving orientation in safety improvement.
May 15, 2024
Bahadurzada H, Kerrissey M, Edmondson AC. Speaking up and taking action: psychological safety and
joint problem-solving orientation in safety improvement. Healthcare (Basel). 2024;12(8):812.…
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psnet.ahrq.gov/node/848823/psn-pdf
May 10, 2023 - Individual characteristics that promote or prevent
psychological safety and error reporting in healthcare: a
systematic review.
May 10, 2023
Wawersik DM, Boutin ER, Gore T, et al. Individual characteristics that promote or prevent psychological
safety and error reporting in healthcare: a systematic review. J Healt…
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psnet.ahrq.gov/node/837507/psn-pdf
June 22, 2022 - Missed nursing care in the critical care unit, before and
during the COVID-19 pandemic: a comparative cross-
sectional study.
June 22, 2022
Falk A-C, Nymark C, Göransson KE, et al. Missed nursing care in the critical care unit, before and during
the COVID-19 pandemic: A comparative cross-sectional study. Intensive…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - anticoagulants
3
4
Case: Watch the Warfarin
A frail 80-year-old man with a past medical history of dementia, 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/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
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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/44693/psn-pdf
June 15, 2016 - This website highlights design
considerations for health care facilities that can help reduce noise, falls
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psnet.ahrq.gov/node/43338/psn-pdf
July 09, 2014 - military-care-pattern-errors-not-scrutiny
https://psnet.ahrq.gov/issue/influence-unit-level-staffing-medication-errors-and-falls-military-hospitals
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psnet.ahrq.gov/node/46552/psn-pdf
October 25, 2017 - https://psnet.ahrq.gov/issue/power-regret
Clinicians may feel regret when the care they provide falls