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5221. One Toxic Drug Is Not Like Another | PSNet
      psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
      October 02, 2019 - July 31, 2023 Patient Safety Innovations Preventing Falls

5222. Debriefing for Clinical Learning | PSNet
      psnet.ahrq.gov/primer/debriefing-clinical-learning
      September 15, 2024 - 30, 2023 Patient Safety Innovations Preventing Falls

5223. Improving Diagnostic Safety and Quality | PSNet
      psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
      January 31, 2024 - May 31, 2023 Patient Safety Innovations Preventing Falls

5224. 023-Ss-Cusp-Learning-From-Defects-Fg (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
      April 01, 2025 - A factor that falls in the category of being a minor reason for the defect and rarely occurs may not

5225. Screening for Osteoporosis to Prevent Fractures: A Systematic Evidence Review for the USPSTF (pdf file)
      www.uspreventiveservicestaskforce.org/home/getfilebytoken/R_cAa3AjFGQ2np_aQnzQGA
      February 11, 2025 - factor for osteoporosis and conducted DXA, vertebral fracture assess- ment, blood chemistry analyses, falls … y or older at high baseline fracture risk; extensive screening battery (imaging, laboratory values, falls … y or older at high baseline fracture risk and extensive screening (imaging, laboratory assessment, falls … Preventing falls is addressed by a separate USPSTF recommendation.216 This review did not address DXA … Interventions to prevent falls in community- dwelling older adults: US Preventive Services Task Force

5226. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49783/psn-pdf
      February 01, 2017 - The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting

5227. Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2022 User Database Report Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/2022-hsops2-database-report.pdf
      January 01, 2022 - 90th %ile Max Item 1 36% 12.26 8% 10% 25% 35% 49% If your hospital’s score is 55%, your score falls … here: 62% If your hospital’s score is 65%, your score falls here: 96% If your hospital’s score … is 55 percent positive, it falls above the 75th percentile (but below the 90th), meaning that your … 2022 SOPS Hospital 2.0 Database Report 53 If your hospital’s score is 65 percent positive, it falls

5228. Final Progress Report: Human Factors and Systems Integration in High Technology Surgery (HF-SIgHTS) (pdf file)
      www.ahrq.gov/sites/default/files/2025-07/catchpole-report.pdf
      January 01, 2025 - performance, infection risk, increased risk of accidental disconnection of devices, and slips, trips and falls … performance, infection risk, increased risk of accidental disconnection of devices, and slips, trips and falls … name when communicating information 6 - Blue cord not covered by safety mat - Patient arm falling

5229. Disposition of Comments Report for Pressure Ulcer Risk Assessment and Prevention (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/pressure-ulcer-prevention_disposition-comments.pdf
      May 08, 2013 - Peer Reviewer #6 Results Page 94, integrated beds are very high and increase the risk of falls and … injury from falls. … mattress, making the side rail ineffective None of the trials of support surfaces/beds reported risk of falls … by the reviewer were included within the patient characteristics described (e.g. functional status falls … Hyde P, Falls K, Morris JA, Schoenwald SK.

5230. Making Healthcare Safer IV_Rapid Review: Use of Structured Handoff Protocols for Intrahospital Within-Unit Transitions (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/structured-handoff-rapid-research.pdf
      January 01, 2025 - The outcomes assessed were a heterogenous mixture of specific events like falls or patient mortality … Other measures of harm declined, but the rate of falls, medication errors, procedure-related errors, … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes-falls, pressure … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes-falls, pressure

5231. Health Information Technology Evaluation Toolkit: 2009 Update (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/health-information-technology-evaluation-toolkit-2009-update.pdf
      January 01, 2009 - patient without external risk factors such as cancer, hyper- coagulable state, and so on) • PE/DVT • Falls … Post-op shock • Pneumothorax intracranial hemorrhage Watch out for documentation effect (e.g., falls … may become more reliably documented because the measure makes it easier to document falls). … The actual number of observations required in this example (i.e., the minimal sample size) falls somewhere

5232. Medical Office SOPS: 2016 User Comparative Database Report, Part I (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/databases/medical-office/2016-report-part-1.pdf
      January 01, 2016 - Sample Percentile Statistics • If your medical office’s score is 55 percent positive, it falls above … • If your medical office’s score is 65 percent positive, it falls above the 90th percentile, meaning … 1 36% 17.43% 8% 10% 25% 35% 49% 62% 96% If your medical office’s score is 55 percent, your score falls … here: If your medical office’s score is 65 percent, your score falls here: 39 Table 6-3.

5233. A National Web Conference on Evaluation of Personal Health Record (PHR) Systems and their Impact on Chronic Disease (pdf file)
      digital.ahrq.gov/sites/default/files/docs/phr-impact-chronic-disease-transcript-012512.pdf
      August 01, 2012 - We have people sometimes during CPAP set ups falling asleep. … Often, the burden falls on the individual or their caregivers to help connect those dots.

5234. Evidence-based Practice Center Systematic Review Protocol (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/patient-safety-practices_research-protocol.pdf
      November 09, 2011 - Evidence-based Practice Center Systematic Review Protocol Source: www.effectivehealthcare.ahrq.gov Published Online: November 9, 2011 Evidence-based Practice Center Systematic Review Protocol Project Title: Critical Analysis of the Evidence for Patient Safety Practices I. Background and Objectives fo…

5235. STATISTICAL BRIEF #478: Trends in Prescribed Outpatient Opioid Use and Expenses in the U.S. Civilian Noninstitutionalized Population, 2002-2012
      meps.ahrq.gov/data_files/publications/st478/stat478.shtml
      August 01, 2015 - STATISTICAL BRIEF #478: Trends in Prescribed Outpatient Opioid Use and Expenses in the U.S. Civilian Noninstitutionalized Population, 2002-2012   Skip to main content An official website of the Department of Health & H…

5236. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
      November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is…

5237. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Cultural Dimensions of Depression March 1, 2012 Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression The Case A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow…

5238. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49406/psn-pdf
      June 01, 2003 - The Dangerous Detour June 1, 2003 Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dangerous-detour The Case Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service for observation after being placed on a 72-hour hold by…

5239. Series Overview | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/evidence-based-reports/er208-overview.html
      October 01, 2014 - Series Overview Closing the Quality Gap: Revisiting the State of the Science Overview of new series of evidence reports on quality improvement strategies. Contents Background Topic Selection and Scope Development Principles Key Questions Organizing Framework References     Background …

5240. Hospital Survey on Patient Safety (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
      June 02, 2025 - Hospital Survey on Patient Safety SOPS TM Hospital Survey Version: 1.0 Language: English Note • For more information on getting started, selecting a sample, determining data collection methods, establishing data collection procedures, conducting a Web-based survey, and preparing and analyzing data, and prod…