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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereportguide.html
September 01, 2017 - cellulitis, dehydration, COPD, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls
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psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
June 30, 2021 - Study
The Stoplight Mobility Alert System for safety and prevention of falls
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap2a.html
October 01, 2014 - Falls Prevention
Appendix 1-A. Suggested Slides for Module 1
Appendix 1-B.
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psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
January 13, 2021 - July 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/
March 25, 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/innovation/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 08, 2021 - Study
The Stoplight Mobility Alert System for safety and prevention of falls
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integrationacademy.ahrq.gov/products/literature-collection/about
September 01, 2024 - Each of the Literature Collection references falls into one or more of the following topics:
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/impaired-visual-acuity-screening-older-adults
June 04, 2020 - to drive and driving outcomes; other measures of morbidity; mortality; cognition; harms, including falls
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digital.ahrq.gov/ahrq-funded-projects/impact-health-it-implementation-diabetes-process-and-outcome-measures
January 01, 2023 - Currently, the health care provided to diabetic patients frequently falls short of the “best care” practices
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hcup-us.ahrq.gov/datainnovations/clinicaldata/ExampleofUsingPOA-CMSHACsusingall-payerdata.pdf
July 01, 2011 - The second most common CMS HAC examined was falls or trauma, which
accounted for another 20 percent … the population at risk, but only 10 percent of
the stage III and IV pressure ulcer, 13 percent of falls … ulcers
Manifestations of poor glycemic control
Catheter-associated urinary tract infection (UTI)
Falls … young adults, older adults had higher rates for the CMS HACs for stage III and IV
pressure ulcers, falls … For example, those 85 years
and older had nearly six times the rate of CMS HACs for falls and trauma
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digital.ahrq.gov/funding-mechanism/advancing-evidence-practice-through-shared-interoperable-clinical-decision-support
January 01, 2023 - Advancing Evidence into Practice through Shared, Interoperable Clinical Decision Support Resources (U18)
Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall Assessment and Prevention Patient-Centered Outcomes Research Findings into Diverse Primary Care Pr…
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digital.ahrq.gov/principal-investigator/hurd-donna
January 01, 2023 - Hurd, Donna
Evaluation of AHRQ's on-time pressure ulcer prevention program: a facilitator-assisted clinical decision support intervention for nursing homes.
Citation
Olsho LE, Spector WD, Williams CS, et al. Evaluation of AHRQ's on-time pressure ulcer prevention program: a fac…
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psnet.ahrq.gov/node/44953/psn-pdf
March 09, 2016 - Patient safety room of horrors: a novel method to assess
medical students and entering residents' ability to identify
hazards of hospitalisation.
March 9, 2016
Farnan JM, Gaffney S, Poston JT, et al. Patient safety room of horrors: a novel method to assess medical
students and entering residents' ability to identi…
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hcup-us.ahrq.gov/reports/statbriefs/sb266-Injuries-Causes-ED-Visits-2017.pdf
January 01, 2017 - Introduction
Injuries are common and can have many causes, such as falls,
cuts, motor vehicle accidents … In
2017, the Centers for Disease Control and Prevention estimated
unintentional falls were the leading … Medicare was the
most common expected payer
for ED visits related to injuries
caused by falls (37.9 … ■ One-third of ED visits related to injuries in 2017 involved falls. … Among ED visits related to injuries in 2017, falls were the most frequent cause of injury, with more
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psnet.ahrq.gov/node/36530/psn-pdf
January 07, 2011 - were much more
likely to report both significant preventable errors and attentional failures (eg, falling
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hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_exhibit2_1.pdf
January 01, 2009 - The rate of stays for circulatory conditions decreased by 13 percent over the 12-year period, falling
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effectivehealthcare.ahrq.gov/sites/default/files/cer-229-opioid-treatments-chronic-pain-evidence-summary.pdf
April 01, 2020 - overdose (intentional and unintentional); and
(3) other harms, including gastrointestinal-
related harms, falls … risk of
fracture and three observational studies found an association between opioid use
and risk of falls … cohort study found modest associations between higher dose of long-term
opioid and increased risk of falls … Association of
opioids with falls, fractures, and physical performance
among older men with persistent … Analgesic use
and risk of recurrent falls in participants with or at risk
of knee osteoarthritis: data
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psnet.ahrq.gov/issue/weekend-versus-weekday-admission-and-mortality-myocardial-infarction
February 18, 2011 - Study
Weekend versus weekday admission and mortality from myocardial infarction.
Citation Text:
Kostis WJ, Demissie K, Marcella SW, et al. Weekend versus Weekday Admission and Mortality from Myocardial Infarction. New England Journal of Medicine. 2007;356(11). doi:10.1056/nejmoa063355.…
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psnet.ahrq.gov/issue/chronic-kidney-disease-adversely-influences-patient-safety
July 29, 2020 - Study
Chronic kidney disease adversely influences patient safety.
Citation Text:
Seliger SL, Zhan M, Hsu VD, et al. Chronic kidney disease adversely influences patient safety. J Am Soc Nephrol. 2008;19(12):2414-9. doi:10.1681/ASN.2008010022.
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psnet.ahrq.gov/issue/venous-thromboembolism-after-trauma-never-event
January 12, 2022 - Study
Venous thromboembolism after trauma: a never event?
Citation Text:
Thorson CM, Ryan ML, Van Haren RM, et al. Venous thromboembolism after trauma: a never event?*. Crit Care Med. 2012;40(11):2967-73. doi:10.1097/CCM.0b013e31825bcb60.
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