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psnet.ahrq.gov/node/49407/psn-pdf
July 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/primer/patient-safety-101
January 16, 2025 - been less harmful if care had been different; Adverse events due to negligence: those due to care that falls
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - April 27, 2022
WebM&M Cases
A Tale of Two Falls
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - May 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - August 16, 2023
Patient falls in the operating room setting: an analysis of reported
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity
Citation Text:
Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting
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psnet.ahrq.gov/node/867850/psn-pdf
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.
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - While this
topic falls outside of the scope of this commentary, it remains critical to treat the whole
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - The nurse's failure to confirm the medication's identity prior to administration falls into the category
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - abdominal pain for 5 hours after eating a greasy meal.
28-year-old G2P1 at 25 weeks’ gestation slips and falls
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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - or huddle with direct frontline team members regarding a
specific safety concern, such as patient falls
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - A Loss of Trust and a Missed Diagnosis
February 23, 2022
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
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/node/72586/psn-pdf
December 23, 2020 - intuitive sense when we think about the sheer number of demands on our
health care teams, but often falls … possible
solutions, but they must be implemented at a system-wide level to ensure no vulnerable patient falls
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
August 01, 2009 - year-old woman presented to the Emergency Department (ED) for evaluation of “altered mental status” after falling
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - that have been adopted by
GRACE for 12 conditions, such as medication management, difficulty walking/falls … A
review of key quality indicators showed an improvement in falls, depression, medication management