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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/engineering-safety-practice/healthcare-safety-competency-environmental-scan.pdf
March 27, 2025 - bloodstream infections, ventilator-associated events, hospital-acquired pressure injuries, patient
falls … rather than
individual improvement efforts in specific areas
such as healthcare-associated infections, falls
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - Patients are at risk of falls. … The "solution" is an assessment form and an action plan related to the risk of falls.
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - Patients are at risk of falls. … The "solution" is an assessment form and an action plan related to the risk of falls.
-
psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - since
experienced higher rates of preventable infections, as well as increases in pressure ulcers and falls … performance measures are associated with measuring and reporting
specific harms, such as an infection, falls
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
-
psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/stroke-atrial-fibrillation_research-protocol.pdf
January 30, 2012 - For patients with AF who are elderly (at high risk for falls), have a history of bleeding, are
pregnant … persistent, or permanent)
International normalized ratio (INR)
Dementia/cognitive impairment
Falls … and permanent)
o International normalized ratio (INR)
o Dementia/cognitive impairment
o Risk of falls
-
digital.ahrq.gov/sites/default/files/docs/publication/r03hs022352-koru-final-report-2014.pdf
January 01, 2014 - Falling through the cracks: Challenges and opportunities for improving transitional
care for persons … Using root cause analysis to reduce falls with injury in
community settings.
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-1-year-final-report-updated-title_0.pdf
May 01, 2024 - Director of the Department of Defense Patient Safety
Program
Defense Health Agency
Falls Church, VA … Interventions to improve prophylaxis for venous
thromboembolism
• Multicomponent interventions to reduce falls … o Most studies found no reduction in falls, but a systematic review reported that half of
the included … studies reduced falls. … studies
• Evidence Summary
o 3 studies examined PFE in fall prevention programs and found reduced falls
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/laparotomy-patient.pdf
November 01, 2023 - Recovering After Emergency Laparotomy
Recovering After
Emergency Laparotomy
e
Emergency Laparotomy Patient Education Guide 1
Recovering After Emergency
Laparotomy
Patient Name ___________________________________________________________________
Surgeon Name ________________________________________________…
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs014965-schmidt-final-report-2007.pdf
January 01, 2007 - Im
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rt
an
ce
S
ca
le
Im
po
rt
an
ce
S
ca
le
Green Zone: Definitely measure any metric falling … Yellow Zone: For metrics falling within this zone, weigh the importance of the metric to the project … Red Zone: The costs of obtaining the data for metrics falling within this zone exceed the value of the
-
effectivehealthcare.ahrq.gov/products/musculoskeletal-disorders-imaging/research-protocol
-
psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - , which could reduce the risk of
heart attack and stroke that may lead to potential disability and falls … augment that with telehealth where you get a view into someone's home and see if there are
tripping or falling
-
psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - August 9, 2023
Cost of inpatient falls and cost-benefit analysis of implementation of
-
www.ahrq.gov/sites/default/files/2024-01/anumba-report_0.pdf
January 01, 2024 - Traumatic are problems such as slips trips or falls.
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/empowerment.html
April 01, 2013 - I know we had implemented a couple years ago, every time a patient falls, we do a post-fall huddle.
-
effectivehealthcare.ahrq.gov/sites/default/files/crosscutting-horizon-scan-high-impact-1406.pdf
June 01, 2014 - designed to
interrupt propofol infusion if the patient’s oxygen saturation level or respiration rate falls … If the onus
of improving patient adherence falls on the provider, staffing needs might increase due … The ED’s physical layout may pose a risk of falls for elderly patients, narrow and thin
mattresses … at Mount Sinai Hospital (New York, NY), reported that “up to eight elderly
patients a month were falling … experts
thought these costs would be offset by reduced readmissions, reduced adverse events (e.g., falls
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2019update.xlsx
June 02, 2025 - 9103359 82 24 3 1 1 1 103 4147 0 0 0 0 0 0 0 0 0 0 0 0 0
HSI00000107 Benefis Healthcare System Great Falls … INS00000177 9101564 0311 271 126 30 6 6 2 453 20658 17.64 0 0 0 0 1 0 0 0 1 1 1 0
HSI00000401 Glens Falls … 0 INS00642888 66 13 8 2 1 1 184 9747 0 0 0 0 0 0 1 0 0 0 0 0 0
HSI00000958 Sanford Health Sioux Falls … 84 11 10 3 1752 82510 134.03 0 0 1 0 1 0 0 0 1 1 1 0
HSI00000994 Sky Lakes Medical Center Klamath Falls … 1 477 16634 72.76 0 0 0 0 1 0 0 0 0 1 0 0
HSI00001143 United Regional Health Care System Wichita Falls
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/chsp-compendium-2019update.csv
June 02, 2025 - 9103359 82 24 3 1 1 1 103 4147 0 0 0 0 0 0 0 0 0 0 0 0 0
HSI00000107 Benefis Healthcare System Great Falls … INS00000177 9101564 0311 271 126 30 6 6 2 453 20658 17.64 0 0 0 0 1 0 0 0 1 1 1 0
HSI00000401 Glens Falls … 0 INS00642888 66 13 8 2 1 1 184 9747 0 0 0 0 0 0 1 0 0 0 0 0 0
HSI00000958 Sanford Health Sioux Falls … 84 11 10 3 1752 82510 134.03 0 0 1 0 1 0 0 0 1 1 1 0
HSI00000994 Sky Lakes Medical Center Klamath Falls … 1 477 16634 72.76 0 0 0 0 1 0 0 0 0 1 0 0
HSI00001143 United Regional Health Care System Wichita Falls