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  1. psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Mentorship: An external expert in care transitions may help a hospital and its BOOST team more effectively … more than 200 hospitals across the U.S. and Canada. … Understanding why there are deficiencies in your current process : Hospitals should complete a root … Deficits in communication and information transfer between hospital-based and primary care physicians … May 31, 2023 Patient Safety Innovations Preventing Falls
  2. psnet.ahrq.gov/issue/common-errors-computer-electrocardiogram-interpretation
    May 08, 2024 - Study Common errors in computer electrocardiogram interpretation. … Common errors in computer electrocardiogram interpretation. Int J Cardiol. 2006;106(2):232-7. … July 1, 2020 Association of the Hospital Readmissions Reduction Program implementation … with readmission and mortality outcomes in heart failure. … November 20, 2024 Reducing falls in hospitalized children and adolescents with cancer
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49594/psn-pdf
    December 01, 2009 - "(3) In this case, the hospital team provided excellent diagnosis and treatment planning. … In one study, 21% were readmitted within 2 weeks compared to 3% in a matched control group.(7) Hospitals … should develop strategies to prevent AMA discharges just as they develop strategies to prevent falls … became the crucial go-between for the hospital staff.(12) Sometimes adjustments in the hospital regimen … Hospitals should plan in advance how to deal with that risk.
  4. psnet.ahrq.gov/issue/effect-hospital-acquired-clostridium-difficile-infection-hospital-mortality
    April 22, 2011 - Study The effect of hospital-acquired Clostridium difficile infection on in-hospital … The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. … antibiotics for other reasons, has become increasingly common in hospitals as well. … The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. … September 21, 2011 Fall prevention in acute care hospitals: a randomized trial.
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866846/psn-pdf
    September 24, 2024 - reporting, and decreases in preventable harm: 39% decrease in injuries with falls, 37% fewer pressure … Describing six domains across which safety culture should be directed, the South Carolina Hospital … Association notes that, since the 2013 launch of their Certified Zero Harm Awards, member hospitals … validated by the state’s Department of Health and Environmental Control with two-thirds of member hospitals … Indeed, the amount of effort expended in the resource scarce environment of hospital administration
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45895/psn-pdf
    February 22, 2017 - Opioids for pain management in older adults: strategies for safe prescribing. … Opioids for pain management in older adults. Nurse Pract. 2017;42(2). … opioids-pain-management-older-adults-strategies-safe-prescribing Use of opioids for pain management in … hospice-diagnosis-polypharmacy-teachable-moment https://psnet.ahrq.gov/issue/nurse-practitioner-led-medication-reconciliation-critical-access-hospitals
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49583/psn-pdf
    April 01, 2009 - 2005, the Joint Commission issued a National Patient Safety Goal requiring hospitals to standardize … Many hospitals have implemented systems designed to comply with the Joint Commission requirement, such … The National Quality Forum also recommends that hospitals establish organization-wide approaches to … psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references https://psnet.ahrq.gov//#references falls … Patient safety and computerized medication ordering at Brigham and Women's Hospital.
  8. psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
    August 01, 2009 - They gave us access to a 42-bed community hospital in Needham, a suburb of Boston. … In my new book, Chasing the Rabbit , I write about Allegheny General Hospital, which had a terrible … like falls and surgical site infections. … But the rest of the hospital is not. … Operational failures and interruptions in hospital nursing. Health Serv Res. 2006;41:643-662.
  9. psnet.ahrq.gov/issue/medical-devices-and-patient-safety
    February 22, 2012 - September 19, 2018 Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter … review of root cause analyses of falls leading to adverse events. … October 19, 2022 Families as partners in hospital error and adverse event surveillance … hospital ICU. … January 27, 2021 Human Factors and Technology in the ICU.
  10. psnet.ahrq.gov/issue/evidence-under-judgment-can-we-oversee-our-own-decision-making
    May 21, 2019 - August 1, 2011 Seroprevalence of SARS-CoV-2 among frontline health care personnel in … a multistate hospital network--13 academic medical centers, April-June 2020. … hospital practice: factors associated with turnover, outcomes, and patient safety. … February 1, 2017 Researchers' roles in patient safety improvement. … September 18, 2013 Partnering to prevent falls: using a multimodal multidisciplinary
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33777/psn-pdf
    January 01, 2015 - It comprises a 336-bed acute care and teaching hospital, a primary and specialty care group practice … Innovation at Virginia Mason Innovation is in the genes of Virginia Mason and is displayed in a rich … Benefits of this approach include reducing the risk of falls, earlier mobilization following surgery … pressed on in their thinking. … In: Plsek PE.
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - In addition, hospitalized seniors are at risk of falls, fractures, and medical/medication errors.2 Older … to complications such as delirium and falls), urinary catheters, or chemical or physical restraints … been adopted by 41 hospitals, health systems and intermediaries in the United States and Canada, including … At Home program, which expanded on the “Hospitals Without Walls” program implemented in response to … Hospital at home versus in-patient hospital care.
  13. psnet.ahrq.gov/issue/neuroscience-critical-care-role-advanced-practice-nurse-patient-safety
    September 21, 2009 - in home care related to patient safety: a cross-sectional survey. … care hospital units. … March 7, 2012 Patient safety incidents describing patient falls in critical care in North … care unit in Thailand. … June 30, 2010 Worries and concerns experienced by nurse specialists during inter-hospital
  14. psnet.ahrq.gov/issue/medical-error-malpractice-and-complications-moral-geography
    August 20, 2018 - In the context of errors, malpractice, and complications, this commentary navigates ethical principles … Resources From the Same Author(s) Education outcomes from a duty-hour flexibility trial in … January 25, 2023 Seroprevalence of SARS-CoV-2 among frontline health care personnel in … a multistate hospital network--13 academic medical centers, April-June 2020. … September 10, 2009 Lawyers say 'sorry' may sink you in court.
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49748/psn-pdf
    December 01, 2015 - upon hospital admission since the presence of alcohol confirms continued drinking and precludes liver … Perhaps the patient in this case was eating more pre-prepared meals, which are high in salt content, … to resolve in the short term. … As you drain fluid, the pressure in the abdomen falls exponentially and very rapidly, leading to a rapid … reduction in right atrial pressure.
  16. psnet.ahrq.gov/web-mm/crossed-coverage
    September 01, 2015 - A similar policy was in place at the admitting hospital in the case described, but it clearly did not … Although not widespread, many hospitals have implemented CPOE with clinical decision support to aid inIn one hospital where CPOE has been in place for a number of years, anticoagulants accounted for 7.2% … Pharmacist-provided anticoagulation management in United States hospitals: death rates, length of stay … High rates of adverse drug events in a highly computerized hospital.
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49754/psn-pdf
    February 01, 2016 - year-old man with poorly controlled diabetes was transferred to a tertiary care center from a community hospital … survey of infection preventionists found that more than 60% of hospitals now have nurse-led PICC teams … patterns.(10) Fueled by an immature evidence base and financial pressures to move patients through the hospital … Although ascertaining tip position generally falls to radiologists, frontline clinicians should remember … Take-Home Points The use of PICCs is on the rise in hospitals across the United States.
  18. psnet.ahrq.gov/issue/facilitating-safe-transition-pediatric-emergency-department-home-post-discharge-phone-call
    March 13, 2015 - March 13, 2015 Medication-related emergency department visits and hospital admissions … hospital-acquired conditions. … April 5, 2023 Insights into the climate of safety towards the prevention of falls among … hospital staff. … hospital practice: factors associated with turnover, outcomes, and patient safety.
  19. psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
    March 03, 2021 - He uses examples of failures from transformation efforts in large and small businesses. … March 3, 2021 How one hospital improved patient safety in 10 minutes a day. … November 2, 2022 Special Issue on Falls. … January 15, 2020 Improving communication with primary care physicians at the time of hospital … August 29, 2011 Challenges in ethics, safety, best practices, and oversight regarding
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73484/psn-pdf
    July 14, 2021 - visitation-restrictions-patient-experience-and-safety- outcomes-critical Research has found that families and caregivers play a key role in … Based on a national sample of hospitals, this study explored the impact of hospital visitation restrictions … Results indicate that hospitals with closed visitations experienced larger performance deficits across

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