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2481. Human factors in patient safety as an innovation. | PSNet
      psnet.ahrq.gov/issue/human-factors-patient-safety-innovation
      June 09, 2021 - January 20, 2021 Information flow during pediatric trauma care transitions: things falling

2482. Beyond patient safety Flatland. | PSNet
      psnet.ahrq.gov/issue/beyond-patient-safety-flatland
      September 04, 2024 - January 9, 2019 View More Related Resources Falling through the

2483. Medical errors: should you apologize? | PSNet
      psnet.ahrq.gov/issue/medical-errors-should-you-apologize
      August 13, 2010 - July 19, 2010 How to avoid falling victim to a hospital mistake.

2484. Implementation, Adoption, and Scaling Workgroup: Exploring Challenges and Opportunities for Patient Engagement, Implementation, Adoption, and Scaling Through PC CDS Case Studies (pdf file)
      cdsic.ahrq.gov/sites/default/files/2024-09/Final%20IAS%20PC%20CDS%20Case%20Studies%20Report_2.pdf
      January 01, 2024 - Health Issue: Older adults, who are at highest risk for falls, need to receive appropriate interventions … However, clinicians do not routinely ask at-risk patients about falls or their associated risk factors … Prior research also shows that patients who experience falls are unlikely to address further fall prevention

2485. Implementation, Adoption, and Scaling Workgroup: Exploring Challenges and Opportunities for Patient Engagement, Implementation, Adoption, and Scaling Through PC CDS Case Studies (pdf file)
      digital.ahrq.gov/sites/default/files/Final%20IAS%20PC%20CDS%20Case%20Studies%20Report_2.pdf
      August 31, 2024 - Health Issue: Older adults, who are at highest risk for falls, need to receive appropriate interventions … However, clinicians do not routinely ask at-risk patients about falls or their associated risk factors … Prior research also shows that patients who experience falls are unlikely to address further fall prevention

2486. The Empty Bag | PSNet
      psnet.ahrq.gov/web-mm/empty-bag
      June 01, 2018 - Evolution and Progress May 1, 2007 WebM&M Cases Falling … February 14, 2024 Patient Safety Innovations Preventing Falls

2487. Elder path tortuosity covaries with MMSE geographical orientation subscale. | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/evaluation-and-integration-automatic-fall-prediction-system/citation/elder-path
      January 01, 2023 - Elder path tortuosity covaries with MMSE geographical orientation subscale. Citation Kearns WD. Elder path tortuosity covaries with MMSE geographical orientation subscale. Gerontechnology 2010;9(2): 176-7. Link http://journal.gerontechnology.org/currentIssueContent.aspx?aid=1178 Principa…

2488. Staff nurse training presentation for the deployment of the CP-CDS tool | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/using-evidence-based-nursing-practices-and-electronic-health-record-decision-4
      January 01, 2023 - Staff nurse training presentation for the deployment of the CP-CDS tool Citation Staff nurse training presentation for the deployment of the CP-CDS tool PDF action-cp-cds-training.pdf Project Name Using Evidence-Based Nursing Practices and Electronic Health Record Decision …

2489. Wireless telesurveillance system for detecting dementia. | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/evaluation-and-integration-automatic-fall-prediction-system/citation/wireless
      January 01, 2023 - Wireless telesurveillance system for detecting dementia. Citation Kearns W, Nams V, Fozard J, et al. Wireless telesurveillance system for detecting dementia. Gerontechnology 2011;10(2):90-102. Link Kearns W, Nams V, Fozard J, et al. Wireless telesurveillance system for detecti… Principal…

2490. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36674/psn-pdf
      January 18, 2011 - An intervention to enhance nursing staff teamwork and engagement. January 18, 2011 Kalisch BJ, Curley M, Stefanov S. An intervention to enhance nursing staff teamwork and engagement. J Nurs Adm. 2007;37(2):77-84. https://psnet.ahrq.gov/issue/intervention-enhance-nursing-staff-teamwork-and-engagement The authors d…

2491. 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…

2492. Data Submission Dashboard Data 2025 (xls file)
      www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2025.xlsx
      January 01, 2025 - 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, 2024. The tables include distributions of events and unsafe conditions reported by PSOs using …

2493. Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. | PSNet
      psnet.ahrq.gov/issue/clinicians-perspectives-proactive-patient-safety-behaviors-perioperative-environment
      May 24, 2023 - Study Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. Citation Text: Duffy C, Menon N, Horak D, et al. Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. JAMA Netw Open. 2023;6(4):e237621. doi:…

2494. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. | PSNet
      psnet.ahrq.gov/issue/patient-safety-factors-and-perceived-consequences-nursing-errors-nursing-staff-home-care
      May 18, 2022 - Study Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. Citation Text: Jachan DE, Müller‐Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. N…

2495. The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. | PSNet
      psnet.ahrq.gov/issue/relationship-between-computerized-physician-order-entry-and-pediatric-adverse-drug-events
      July 13, 2009 - Study The relationship between computerized physician order entry and pediatric adverse drug events: a nested matched case-control study. Citation Text: Yu F, Salas M, Kim Y-I, et al. The relationship between computerized physician order entry and pediatric adverse drug events: a nested…

2496. Department of anesthesiology skilled peer support program outcomes: second victim perceptions. | PSNet
      psnet.ahrq.gov/issue/department-anesthesiology-skilled-peer-support-program-outcomes-second-victim-perceptions
      April 12, 2011 - Study Department of anesthesiology skilled peer support program outcomes: second victim perceptions. Citation Text: Bursch B, Ziv K, Marchese S, et al. Department of anesthesiology skilled peer support program outcomes: second victim perceptions. Jt Comm J Qual Patient Saf. 2024;50(6):44…

2497. Disparities in patient safety voluntary event reporting: a scoping review. | PSNet
      psnet.ahrq.gov/issue/disparities-patient-safety-voluntary-event-reporting-scoping-review
      November 16, 2022 - Review Disparities in patient safety voluntary event reporting: a scoping review. Citation Text: Hoops K, Pittman E, Stockwell DC. Disparities in patient safety voluntary event reporting: a scoping review. Jt Comm J Qual Patient Saf. 2024;50(1):41-48. doi:10.1016/j.jcjq.2023.10.009. Co…

2498. Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department. | PSNet
      psnet.ahrq.gov/issue/situation-background-assessment-and-recommendation-guided-huddles-improve-communication-and
      September 23, 2020 - Study Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department. Citation Text: Martin HA, Ciurzynski SM. Situation, Background, Assessment, and Recommendation-Guided Huddles Improve Communication and Teamwork in t…

2499. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? | PSNet
      psnet.ahrq.gov/issue/patient-safety-and-image-transfer-between-referring-hospitals-and-neuroscience-centres-could
      July 19, 2023 - Study Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better? Citation Text: Crocker M, Cato-Addison WB, Pushpananthan S, et al. Patient safety and image transfer between referring hospitals and neuroscience centres: could we do bette…

2500. Communication failures contributing to patient injury in anaesthesia malpractice claims. | PSNet
      psnet.ahrq.gov/issue/communication-failures-contributing-patient-injury-anaesthesia-malpractice-claims
      August 04, 2021 - Study Communication failures contributing to patient injury in anaesthesia malpractice claims. Citation Text: Douglas RN, Stephens LS, Posner KL, et al. Communication failures contributing to patient injury in anaesthesia malpractice claims. Br J Anaesth. 2021;127(3):470-478. doi:10.1016…