-
psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - May 31, 2023
Patient Safety Innovations
Preventing Falls
-
psnet.ahrq.gov/web-mm/language-barrier
February 28, 2024 - Language Barrier
Citation Text:
Flores G. Language Barrier. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Cita…
-
psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - The Empty Bag
December 1, 2016
Vincent C. The Empty Bag. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/empty-bag
The Case
A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a
hip fracture after a fall at a nursing home. During the hospitalization, her kidne…
-
psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
-
psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - While this topic falls outside of the scope of this commentary, it remains critical to treat the whole
-
psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - The rates of infection, bleeding, blood clots, and falls were
increasing—in addition to the risk of
-
psnet.ahrq.gov/node/49468/psn-pdf
December 16, 2004 - Mark My Limb
December 1, 2004
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/mark-my-limb
The Case
A patient went to the operating room (OR) for surgery on the lower leg. Per the Universal Protocol, the
surgeon marked the proper leg prior to bringing the patient to the O…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
November 01, 2018 - Case: Supervision and Entrustment
A 65-year-old man was admitted with head and spine trauma after falling
-
psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - We have individuals going out into individual homes, where some serious events occur, like patient falls … to examine patterns across multiple events within a category (such as medication errors or patient falls
-
psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - to examine patterns across multiple events within a category (such as medication errors or patient falls … We have individuals going out into individual homes, where some serious events occur, like patient falls
-
psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - make it problematic to generalize from the hand hygiene experience to let's say trying to decrease falls … Prostatic Hyperplasia
August 10, 2019
Remote patient monitoring improves patient falls
-
psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
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
-
psnet.ahrq.gov/node/33879/psn-pdf
May 01, 2019 - In Conversation With… Jane Brice, MD, MPH
May 1, 2019
In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University
of North Carolina. She…
-
psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
-
psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
-
psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - infection can initially present with nonspecific symptoms including fatigue, generalized weakness, falls
-
psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - Related Resources
Patient Safety Innovations
Preventing Falls
-
psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - s authors shows that including patients and families during care transitions
reduces harms such as falls
-
psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Important topics like health care disparities, personal
technology, and much of what falls under the