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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - Number one, because there's a notion that this is not something that falls within our accountability.
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - infection (such as catheter-associated urinary tract infection or aspiration pneumonia), pressure ulcers, falls
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Two common approaches are either to (i) order an unbound phenytoin level to see whether it falls within
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - Patients should
lie supine during the exam to avoid vasovagal reactions that could lead to falls and
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - • Patients should lie supine during the exam to avoid vasovagal reactions that could
lead to falls
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - The second major avenue falls more on the psychometric disciplines.
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psnet.ahrq.gov/node/33793/psn-pdf
November 01, 2015 - research on clinical interventions to prevent hospital–acquired adverse events, VTE prophylaxis, or falls
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - psychiatric units were medication errors (17.2 per 100 discharges), adverse drug
events (4.1), and falls
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psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
March 24, 2025 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - July 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - the finding before recommending management limited to routine mammography screening.” 12 BI-RADS 3 falls
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - 30, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - May 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - 28, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - 30, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/49783/psn-pdf
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/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
-
psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Are We Pushing Graduate Nurses Too Fast?
March 1, 2011
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
The Case
A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
-
psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
-
psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Outbreak
May 1, 2011
Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/outbreak
The Case
A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He
presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…