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441. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
     January 01, 2010 - He gets more restless, gets out of bed, trips on the catheter and falls. … We traditionally thought that a catheter was helpful in preventing falls because patients didn’t have … However, the catheter doesn’t eliminate the urge to urinate and the tubing can cause tripping and falling

442. Blood Thinner Pills: Your Guide to Using Them Safely (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.pdf
     September 01, 2015 - Blood Thinner Pills: Your Guide to Using Them Safely Blood Thinner Pills: Your Guide to Using Them Safely AHRQ Pub. No. 15-0047-C Replaces AHRQ Pub. No. 09-0086-C September 2015 The name of my blood thinner is: _____________________________________________________________ Reminders: Call your doctor or phar…

443. Final Progress Report: Staff Nurse Fatigue and Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/rogers-report.pdf
     January 01, 2024 - once during the 28-day data-gathering period, and 16.8% of the participants (152 nurses) reported falling … Nurses reported struggling to stay awake once every five shifts worked (2285/11,329 shifts) and falling … Nurses who reported struggling to stay awake on duty and/or actually falling asleep on duty obtained … US workers.33 The high frequency of which nurses reported struggling to stay awake and/or actual falling … Participants in the AACN study who reported falling asleep on duty obtained on average 6.6 hours sleep

444. Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-reimagining-healthcare-teams.pdf
     July 07, 2023 - process hundreds of thousands of heartbeats in seconds22, 23 and others that can automatically track falls … ensuring the technology is worn, while the AI would provide daily summaries about fall risk and near falls … This information could lead to interventions to prevent falls. … Automated loss-of-balance event identification in older adults at risk of falls during real-world walking

445. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/treat-release.html
     September 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Electronic Reports Table 4. Sample ED Treat and Release Report Facility Name: Month: Average Daily Census 30 Total Transfers (Obs, ED) 11 Resident Days (including bed holds) 300 Tot…

446. Data Submission Dashboard (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2024.xlsx
     January 01, 2024 - Data Submission Dashboard Introduction Introduction-Data Submission Summary The tables in this workbook present data submitted by AHRQ-listed Patient Safety Organizations (PSOs) to the Network of Patient Safety Databases (NPSD) through December 31, 2023. The tables include distributions of events and unsaf…

447. SOPS Workplace Safety Supplemental Items for Nursing Homes: 2025 Updated Results Part I (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025_nursing_home_wps_ptI.pdf
     January 01, 2025 - Max Item 1 36% 12.26 8% 10% 25% 35% 49% 62% 96% If your nursing home’s score is 55%, your score falls … here: If your nursing home’s score is 65%, your score falls here: If your nursing home’s score is … 55 percent positive, it falls above the 75th percentile (but below the 90th), meaning that your nursing … If your nursing home’s score is 65 percent positive, it falls above the 90th percentile, meaning your

448. SOPS Workplace Safety Supplemental Items for Nursing Homes: 2025 Updated Results Part I (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/2025-nursing-home-workplace-safety-report-pt1.pdf
     January 01, 2025 - Max Item 1 36% 12.26 8% 10% 25% 35% 49% 62% 96% If your nursing home’s score is 55%, your score falls … here: If your nursing home’s score is 65%, your score falls here: If your nursing home’s score is … 55 percent positive, it falls above the 75th percentile (but below the 90th), meaning that your nursing … If your nursing home’s score is 65 percent positive, it falls above the 90th percentile, meaning your

449. Using the CAHPS Database to Compare, Report, and Improve Organizational Performance (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20140115_DB/2_Janice_Ricketts_slides_12-28.pdf
     January 01, 2014 - Using the CAHPS Database to Compare, Report, and Improve Organizational Performance CAHPS Database Online Reporting System 12 CAHPS Database 13 • The CAHPS Database receives data voluntarily submitted by users that have administered: – Clinician & Group Survey – Health Plan Survey • Data are submitt…

450. Interview with the OPTIMA Project Team | Agency for Healthcare Research and Quality
     www.ahrq.gov/evidencenow/projects/urinary/optima-interview.html
     November 01, 2024 - Recognizing that UI is highly stigmatized and the burden of initiating a UI conversation often falls

451. Prevehosp-Reports-Ig (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-reports-ig.pdf
     November 30, 2013 - cellulitis, dehydration, COPD, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls

452. Development of the CAHPS Adult Hospital Survey | Agency for Healthcare Research and Quality
     www.ahrq.gov/cahps/surveys-guidance/hospital/about/dev_adult_hp_survey.html
     January 01, 2025 - Development of the CAHPS Adult Hospital Survey The  CAHPS Hospital Survey  was conceived first and foremost as a tool for public reporting purposes. While many hospitals already conduct some type of patient survey, CMS needed a standardized instrument that would allow consumers to compare inpatients' perspectiv…

453. Emergency Departments Don’t Coordinate How They Collect, Use Social Needs Information | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsletters/e-newsletter/918.html
     June 01, 2024 - Articles featured this week include: Interventions to prevent falls in older adults: updated evidence

454. Using Root Cause Analysis to Improve Quality and Performance | Agency for Healthcare Research and Quality
     www.ahrq.gov/evidencenow/tools/root-cause-analysis.html
     February 01, 2025 - Using Root Cause Analysis to Improve Quality and Performance Resource: Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes  (PDF, 908 KB, 18 pages) Part of an AHRQ curriculum used to train practice facilitators, this resource describes how practices can use a roo…

455. Final Progress Report: Disseminating a Web-Enabled Safety Risk Assessment (SRA) Toolkit for Designing Safer Healthcare Facilities (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/taylor-report.pdf
     January 01, 2025 - Scope: The SRA toolkit covers six safety areas – infection control, medication safety, falls, patient … The workgroups were organized around six key safety areas: infection control, medication safety, falls … Validation testing took place in conference rooms at three sites, one study session in Falls Church, … reported to The Joint Commission have an underlying cause in the physical environment (i.e., suicide, falls … One study session took place in Falls Church, VA, and two were in in Philadelphia, PA.

456. Health Equity | Agency for Healthcare Research and Quality
     www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-health-equity.html
     May 01, 2024 - The most common unintentional injury was drug overdose, accidental falls, and motor vehicle accidents

457. Final Progress Report: Quality Care and Error Reduction in Rural Hospitals (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/cook-hoas-report.pdf
     January 01, 2024 - of problems most typically recognized and identified as problematic (medication errors and patient falls … encountered only medication-related errors (the wrong time, dose, drug, or mode of delivery), patient falls … hospital detailed organizational efforts to reduce medication errors and, to a lesser degree, patient falls … context, most errors are attributed to the nursing staff, so overall responsibility for patient safety falls

458. Strategies to Better Engineer Safety into Healthcare Delivery (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/safety-engineering-strategies.pdf
     March 06, 2025 - competing design priorities and demonstrates how a participatory design process focused on preventing falls … By addressing these aspects, the study aims to improve patient room design and reduce the risk of falls

459. Final Progress Report: Patient Safety in Hospice Care (pdf file)
     www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
     January 01, 2024 - Injuries from falls: Common contributing factors for falls leading to harm included: • Patients living

460. Blood Thinner Pills: Your Guide to Using Them Safely | Agency for Healthcare Research and Quality
     www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.html
     March 01, 2023 - Blood Thinner Pills: Your Guide to Using Them Safely The Agency for Healthcare Research and Quality offers a free booklet and a video about blood thinner medicines. Staying Active and Healthy with Blood Thinners , a 10-minute video, features easy-to-understand explanations of how blood thinners wor…