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Showing results for "falls".
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2001. Spotlight Case July 2008 (ppt file)
      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

2002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33852/psn-pdf
      January 01, 2017 - experiences had no impact on a global measure of safety including outcomes like urinary tract infections and falls

2003. Readmissions and Adverse Events After Discharge | PSNet
      psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
      April 27, 2022 - weakness and increased stress that may leave patients vulnerable to clinical adverse events such as falls

2004. 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 - Benefits of this approach include reducing the risk of falls, earlier mobilization following surgery,

2005. Psn-Pdf (pdf file)
      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

2006. Psn-Pdf (pdf file)
      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

2007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35009/psn-pdf
      May 27, 2011 - prescription of recommended doses, decreased prescription of nonrecommended drugs, and fewer inpatient falls

2008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43016/psn-pdf
      May 28, 2014 - Identification of serious and reportable events in home care: a Delphi survey to develop consensus. May 28, 2014 Doran DM, Baker R, Szabo C, et al. Identification of serious and reportable events in home care: a Delphi survey to develop consensus. Int J Health Care Qual. 2014;26(2):136-143. doi:10.1093/intqhc/mzu00…

2009. Preventable Transfer to the Hospital | PSNet
      psnet.ahrq.gov/web-mm/preventable-transfer-hospital
      March 31, 2022 - 27, 2024 Patient Safety Innovations Preventing Falls

2010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838916/psn-pdf
      October 26, 2022 - Falling through the cracks: the invisible hospital cleaning workforce. … Falling through the cracks: the invisible hospital cleaning workforce. … https://psnet.ahrq.gov/issue/falling-through-cracks-invisible-hospital-cleaning-workforce Disinfection … https://psnet.ahrq.gov/issue/falling-through-cracks-invisible-hospital-cleaning-workforce https://psnet.ahrq.gov

2011. High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
      February 26, 2025 - together, high reliability principles are associated with lower levels of medication errors and patient falls … (measured on a 1-to-7 scale) was associated with 25% fewer medication errors and 37% fewer patient falls … high reliability approaches are associated with things like fewer medication errors, fewer patient falls … And the source of both becoming highly reliable and falling apart was leadership.

2012. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
      February 26, 2025 - high reliability approaches are associated with things like fewer medication errors, fewer patient falls … And the source of both becoming highly reliable and falling apart was leadership. … together, high reliability principles are associated with lower levels of medication errors and patient falls … (measured on a 1-to-7 scale) was associated with 25% fewer medication errors and 37% fewer patient falls

2013. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49513/psn-pdf
      July 01, 2006 - What is the expected level of intervention (eg, replace an oxygen mask if it falls off, silence an IV

2014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42855/psn-pdf
      February 06, 2014 - Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients. February 6, 2014 Driver TH, Katz PP, Trupin L, et al. Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients. J H…

2015. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47666/psn-pdf
      January 01, 2020 - 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. February 6, 2019 Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured Postoperative Ha…

2016. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49785/psn-pdf
      February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…

2017. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49598/psn-pdf
      February 01, 2010 - The patient denied any history of arrhythmia, syncope, presyncope, dementia, or prior falls.

2018. Diagnostic Errors Case Studies | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
      August 10, 2025 - An elderly man had iron deficiency anemia with progressively falling … Linkedin Copy URL An elderly man had iron deficiency anemia with progressively falling

2019. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet
      psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
      February 28, 2024 - seen frequently with virtual teams where a diagnosis isn’t communicated quickly enough, or something falls … Perspective The Ongoing Journey to Prevent Patient Falls … In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls

2020. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47858/psn-pdf
      July 10, 2019 - patients in Ireland found that they were frequently prescribed medications that increased their risk of falling