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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - these five things to prevent catheter-associated bloodstream infections, these seven things to prevent falls … scientific evidence that if you do these five things you will prevent most decubitus ulcers, or most falls
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - include infections, hypotension, electrolyte disturbances, blood loss, adverse drug effects, and patient falls … Home Care
Nephrology
Side Effects/Adverse Drug Reactions
Nosocomial Infections
Patient Falls
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - A review of key quality indicators showed an improvement in falls, depression, medication management, … that have been adopted by GRACE for 12 conditions, such as medication management, difficulty walking/falls
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - Common events (e.g., health care–associated infections, falls) may be so common that individual hospitals … common types of events, such as health care–associated infections, medication errors, pressure ulcers, falls
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - Number one, because there's a notion that this is not something that falls within our accountability. … 31, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - common types of events, such as health care–associated infections, medication errors, pressure ulcers, falls … Common events (e.g., health care–associated infections, falls) may be so common that individual hospitals
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - heparin, with a plan to initiate warfarin once it became clear that that she was not at high risk for falls
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - August 26, 2020
Do falls and other safety issues occur more often during handovers when
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - The responsibility to provide education falls on both the prescriber and the dispensing pharmacist.
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - 31, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
falls
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - Geriatric Patients
Older adults are at risk for adverse events from medications, including delirium and falls
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - to a lack of timely language assistance include performing an x-ray on the wrong part of the
body, falls
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - this class of drugs is frequently associated with errors that can result in adverse
events including falls
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - Wait until aPTT is
For INRs significantly above the therapeutic range, hold warfarin until INR falls
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psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
February 26, 2025 - achieved performance goals but also supports accountability and data transparency when performance falls
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psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - or unit without assistance place themselves at risk for specific
complications, including slips and falls
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication
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psnet.ahrq.gov/node/49754/psn-pdf
February 01, 2016 - Although ascertaining tip position generally falls to radiologists, frontline clinicians should remember