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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - In addition, hospitalized seniors are at risk of falls, fractures, and medical/medication errors. 2 … were less likely to receive IV fluids, sedatives (which can lead to complications such as delirium and falls
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - For many patient safety problems, that type of applied epidemiological approach is appropriate: falls … January 9, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - significantly improve a number of patient
outcomes, including lower rates of surgical site infections, falls … https://psnet.ahrq.gov/issue/impact-safety-culture-quality-care-missed-care-and-nurse-staffing-patient-falls-multisource
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - he had multiple ED visits with similar episodes of syncope in the preceding months all resulting in falls … Chart review or additional history-taking may have revealed the patient’s recent history of falls with
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - They started tackling some really tough problems:
patient falls, surgical site infections, central line … region as a whole cut the infection rate 70%, and
other hospitals eliminated other "never events" like falls
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - But it falls
short because it emphasizes the few things that go wrong rather than seeking to understand
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Although rare, adverse events during
early mobilization have included falls, line dislodgement, ventilator
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - Agreement
September 24, 2024
Patient Safety Primers
Falls
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Common events (e.g., health care–associated
infections, falls) may be so common that individual hospitals
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - experience, and
prevention of patient safety events and adverse events such as medication issues, falls
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Related Resources
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - Returning Home Safely
Citation Text:
Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/issue/widows-mission-change-nc-dental-sedation-rules
March 10, 2021 - Newspaper/Magazine Article
A widow’s mission to change NC dental sedation rules.
Citation Text:
A widow’s mission to change NC dental sedation rules. Blythe A. NC Health News. March 10, 2022
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psnet.ahrq.gov/issue/overreaction
November 15, 2023 - Newspaper/Magazine Article
Overreaction.
Citation Text:
Shell ER. Overreaction. Scientific American. 2015;313(5):28-9.
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psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or
September 14, 2016 - Newspaper/Magazine Article
Accidental IV infusion of heparinized irrigation in the OR.
Citation Text:
Accidental IV infusion of heparinized irrigation in the OR. ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
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psnet.ahrq.gov/issue/using-simulation-improve-systems-0
July 22, 2020 - Review
Using simulation to improve systems.
Citation Text:
Kearney JA, Deutsch ES. Using Simulation to Improve Systems. Otolaryngol Clin North Am. 2017;50(5):1015-1028. doi:10.1016/j.otc.2017.05.011.
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psnet.ahrq.gov/issue/racism-derails-black-mens-health-even-education-levels-rise
May 28, 2014 - Newspaper/Magazine Article
Racism derails black men’s health, even as education levels rise.
Citation Text:
Racism derails black men’s health, even as education levels rise. Anderson V. Kaiser Health News. May 19, 2021
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psnet.ahrq.gov/issue/bleeding-and-pain-pregnant-woman-louisiana-couldnt-get-answers
January 18, 2023 - Newspaper/Magazine Article
Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.
Citation Text:
Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers. Westwood R. Kaiser Health News. January 12, 2023.
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psnet.ahrq.gov/issue/he-thought-what-he-was-doing-was-good-people-why-it-so-difficult-prevent-unnecessary-medical
September 02, 2020 - Newspaper/Magazine Article
‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system?
Citation Text:
‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessa…
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psnet.ahrq.gov/issue/technology-and-error-prevention-strategies-why-are-we-still-overlooking-iv-room
July 08, 2015 - Newspaper/Magazine Article
Technology and error-prevention strategies: why are we still overlooking the IV room?
Citation Text:
Technology and error-prevention strategies: why are we still overlooking the IV room? ISMP Medication Safety Alert! Acute Care Edition. January 15, 2015;20:1-4.…