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3781. EHR safety: the way forward to safe and effective systems. | PSNet
      psnet.ahrq.gov/issue/ehr-safety-way-forward-safe-and-effective-systems
      December 12, 2012 - Commentary EHR safety: the way forward to safe and effective systems. Citation Text: Walker JM, Carayon P, Leveson N, et al. EHR safety: the way forward to safe and effective systems. J Am Med Inform Assoc. 2008;15(3):272-7. doi:10.1197/jamia.M2618. Copy Citation Format: …

3782. Defining and classifying terminology for medication harm: a call for consensus. | PSNet
      psnet.ahrq.gov/issue/defining-and-classifying-terminology-medication-harm-call-consensus
      June 22, 2022 - Review Defining and classifying terminology for medication harm: a call for consensus. Citation Text: Falconer N, Barras M, Martin J, et al. Defining and classifying terminology for medication harm: a call for consensus. Eur J Clin Pharmacol. 2019;75(2):137-145. doi:10.1007/s00228-018-25…

3783. Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. | PSNet
      psnet.ahrq.gov/issue/medication-administration-variances-and-after-implementation-computerized-physician-order
      July 19, 2023 - Study Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. Citation Text: Taylor JA, Loan LA, Kamara J, et al. Medication administration variances before and after implementation of computerized phy…

3784. Current approaches to punitive action for medication errors by boards of pharmacy. | PSNet
      psnet.ahrq.gov/issue/current-approaches-punitive-action-medication-errors-boards-pharmacy
      May 26, 2011 - Study Current approaches to punitive action for medication errors by boards of pharmacy. Citation Text: Holdsworth M, Wittstrom K, Yeitrakis T. Current approaches to punitive action for medication errors by boards of pharmacy. Ann Pharmacother. 2013;47(4):475-81. doi:10.1345/aph.1R668. …

3785. Five ways you can reduce inappropriate prescribing in the elderly: a systematic review. | PSNet
      psnet.ahrq.gov/issue/five-ways-you-can-reduce-inappropriate-prescribing-elderly-systematic-review
      September 23, 2020 - Review Five ways you can reduce inappropriate prescribing in the elderly: a systematic review. Citation Text: Garcia RM. Five ways you can reduce inappropriate prescribing in the elderly: a systematic review. J Fam Pract. 2006;55(4):305-12. Copy Citation Format: Google Sc…

3786. Deploying Six Sigma in a health care system as a work in progress. | PSNet
      psnet.ahrq.gov/issue/deploying-six-sigma-health-care-system-work-progress
      March 04, 2011 - Study Deploying Six Sigma in a health care system as a work in progress. Citation Text: Christianson JB, Warrick LH, Howard R, et al. Deploying Six Sigma in a health care system as a work in progress. Jt Comm J Qual Patient Saf. 2005;31(11):603-13. Copy Citation Format: Goo…

3787. Impact and culture change after the implementation of a preprocedural checklist in an interventional radiology department. | PSNet
      psnet.ahrq.gov/issue/impact-and-culture-change-after-implementation-preprocedural-checklist-interventional
      May 05, 2021 - Study Impact and culture change after the implementation of a preprocedural checklist in an interventional radiology department. Citation Text: Wong SSN, Cleverly S, Tan KT, et al. Impact and Culture Change After the Implementation of a Preprocedural Checklist in an Interventional Radiol…

3788. Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections. | PSNet
      psnet.ahrq.gov/issue/frequent-diagnostic-errors-cardiac-petct-due-misregistration-ct-attenuation-and-emission-pet
      December 22, 2018 - Study Frequent diagnostic errors in cardiac PET/CT due to misregistration of CT attenuation and emission PET images: a definitive analysis of causes, consequences, and corrections. Citation Text: Gould L, Pan T, Loghin C, et al. Frequent diagnostic errors in cardiac PET/CT due to misre…

3789. Module 2. Communicating Change in a Resident's Condition | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod2.html
      October 01, 2014 - Falls Prevention Appendix 1-A. Suggested Slides for Module 1 Appendix 1-B. … stretch" goal that may be hard to reach but is achievable, for example: To decrease the rate of resident falls … a responsible member of the center to ensure that the improvement is sustained over time and, if it falls

3790. Final Progress Report: Identification and Dissemination of Best Practices for Patient-Centered Care (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/aboumatar-report.pdf
      January 01, 2024 - and to participate in systems of care that are responsive to their needs.” [1] Hospital care often falls … adve rse events and preventable readmissions to the hospital, and about 50% of inpatient hospital falls … Characteristics and Circumstances of Falls in a Hospital Setting.

3791. Technical Interventions To Prevent CAUTI | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/guides/implguide-pt3.html
      October 01, 2015 - catheters, based on the Ann Arbor Criteria, include the following: Attempting to reduce risk for falls … patients with UTI Indwelling urinary catheter use has not been found to be effective in reducing falls … external catheter Routine use in ICU without an appropriate indication To attempt to reduce risk for falls

3792. Promoting Best Practice and Safety Through Preprinted Physician Orders (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Ehringer_17.pdf
      February 08, 2008 - • The schedule (and stacking) of medications can contribute to falls in the elderly. … for every-12-hour diuretic medications from 9 am and 9 pm to 9 am and 5 pm can decrease nighttime falls … into the process increases effectiveness;15, 17, 19 for example: • This drug may increase risk of falls

3793. Recommendation: Cognitive Impairment in Older Adults: Screening | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening
      February 25, 2020 - with harms, some of which are serious, including central nervous system disturbances, bradycardia, and falls … individual studies reported increased rates of serious adverse events, such as bradycardia, syncope, falls … associated with adverse effects, which overall are small but occasionally serious, including syncope or falls

3794. Patient Safety During Hospital Discharge | PSNet
      psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
      April 01, 2018 - Impaired mobility from deconditioning increases the risk of falls, as well as preventing the patient … The rates of infection, bleeding, blood clots, and falls were increasing—in addition to the risk of whatever … 15, 2024 Patient Safety Innovations Preventing Falls

3795. Workarounds and Resiliency on the Front Lines of Health Care | PSNet
      psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
      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 … Perspective The Ongoing Journey to Prevent Patient Falls

3796. Fbqmoapkebekmj7Aqmale5 (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/fbQmoAPKeBekmJ7aqmALe5
      June 01, 2014 - impairment, including counseling on tobacco cessation, alcohol use, healthful diet, physical activity, and falls … impairment, including counseling on tobacco cessation, alcohol use, healthful diet, physical activity, and falls … Bradycardia and adverse effects related to it (such as falls and syncope) may result from taking AChEIs

3797. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
      April 01, 2013 - So again, if you’re looking at falls, you would use the evidence-based practices to prevent falls.

3798. 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/impmaterials.html
      June 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits Hospital Transfer Self-Assessment Worksheet Purpose The Hospital Transfer Self-Assessment Worksheet can help nursing home staff identify and review care that they provide that may lead to avoidable transf…

3799. AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/3.html
      December 01, 2017 - AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention Functional Specifications 3. Specifications for Each Pressure Ulcer Prevention Report (continued) 3.3. Weight Summary Report 3.3.1. Report Description The Weight Summary Report displays 4 weeks of trended weight information for e…

3800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866395/psn-pdf
      July 23, 2024 - Rescue Improvement Conference Innovation Summary July 23, 2024 https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary Summary The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure to rescue with a particular focus on communication and com…