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1721. Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures. | PSNet
      psnet.ahrq.gov/issue/not-overstepping-professional-boundaries-challenging-role-nurses-simulated-error-disclosures
      August 04, 2021 - Study Not overstepping professional boundaries: the challenging role of nurses in … October 19, 2011 Perceptions of nurses who are second victims in a hospital setting. … a US Hospital. … March 21, 2018 Do falls and other safety issues occur more often during handovers when … caregivers to improve safety and facilitate person- and family-centered care during transitions from hospital

1722. Keeping safety a priority in home care and hospice: one agency's journey. | PSNet
      psnet.ahrq.gov/issue/keeping-safety-priority-home-care-and-hospice-one-agencys-journey
      June 05, 2019 - Keeping safety a priority in home care and hospice: one agency's journey. … Keeping safety a priority in home care and hospice: one agency's journey. … August 16, 2023 Patient Safety Innovations Preventing Falls … September 18, 2016 Towards safer transitions: a curriculum to teach and assess hospital-to-hospice … July 8, 2009 How safe are patients in primary care?

1723. The effects of emergency department staff rounding on patient safety and satisfaction. | PSNet
      psnet.ahrq.gov/issue/effects-emergency-department-staff-rounding-patient-safety-and-satisfaction
      November 16, 2022 - Regularly scheduled rounds by nursing staff reduced falls and improved patient satisfaction in this multi-institutional … hospital practice: factors associated with turnover, outcomes, and patient safety. … July 10, 2019 Hospital readmission and parent perceptions of their child's hospital discharge … November 26, 2008 Improving patient safety in intensive care units in Michigan. … May 29, 2024 Overnight stay in the emergency department and mortality in older patients

1724. When the 5 rights go wrong: medication errors from the nursing perspective. | PSNet
      psnet.ahrq.gov/issue/when-5-rights-go-wrong-medication-errors-nursing-perspective
      June 27, 2018 - Exploring organizational context and structure as predictors of medication errors and patient falls … hospital practice: factors associated with turnover, outcomes, and patient safety. … January 18, 2023 Realist synthesis of intentional rounding in hospital wards: exploring … the evidence of what works, for whom, in what circumstances and why. … the hospital setting: a prospective observational study.

1725. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet
      psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
      January 01, 2015 - Benefits of this approach include reducing the risk of falls, earlier mobilization following surgery, … We spoke with him about applying Lean in hospitals. Dr. … It's no accident that some early adopters of Lean in hospitals were clinical laboratories, where there … In hospital lab settings, there are huge opportunities to improve the way we manage and to engage employees … It's trying to take these caring individuals and caring settings and making the hospital the best hospital

1726. Statement on the prevention of retained foreign bodies after surgery. | PSNet
      psnet.ahrq.gov/issue/statement-prevention-retained-foreign-bodies-after-surgery
      October 15, 2018 - The statement was revised in October 2016. … October 15, 2018 Surgical Patient Safety Essential Information for Surgeons in Today's … December 17, 2024 Preventing Patient Falls: A Systematic Approach From the Joint Commission … October 27, 2016 Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0

1727. Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington. | PSNet
      psnet.ahrq.gov/issue/outbreak-investigation-covid-19-among-residents-and-staff-independent-and-assisted-living
      October 19, 2022 - COVID-19 among residents and staff of an independent and assisted living community for older adults in … COVID-19 among residents and staff of an independent and assisted living community for older adults in … of early surveillance and prevention strategies in reducing virus transmission in assisted living communities … hospital practice: factors associated with turnover, outcomes, and patient safety. … November 1, 2016 Latency of ECG displays of hospital telemetry systems: a science advisory

1728. Structural racism--a 60-year-old black woman with breast cancer. | PSNet
      psnet.ahrq.gov/issue/structural-racism-60-year-old-black-woman-breast-cancer
      December 17, 2020 - in patient-level quality measures; (2) health care organizations can engage the community in an effort … May 4, 2022 Error and cognitive bias in diagnostic radiology. … August 5, 2020 'I'm smiling under here': Masks, plexiglass and questions the norm as hospitals … lure patients back in COVID-19 era. … September 28, 2010 View More See More About The Topic Hospitals Facility

1729. Association of default electronic medical record settings with health care professional patterns of opioid prescribing in emergency departments: A randomized quality improvement study | PSNet
      psnet.ahrq.gov/issue/association-default-electronic-medical-record-settings-health-care-professional-patterns
      February 12, 2020 - default electronic medical record settings with health care professional patterns of opioid prescribing in … Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in … Prescription opioids play a significant role in the ongoing opioid crisis . … This study examined whether reducing the default settings in the electronic health record (EHR) for … Stigmatizing language and the transmission of bias in the medical record.

1730. Investigation of interventions to reduce nurses' medication errors in adult intensive care units: a systematic review. | PSNet
      psnet.ahrq.gov/issue/investigation-interventions-reduce-nurses-medication-errors-adult-intensive-care-units
      September 29, 2021 - Review Investigation of interventions to reduce nurses' medication errors in adult … fall prevention in a nursing home. … hospitals: a systematic review. … Indications for Drug Administration Blur June 24, 2020 Safety enhancements every hospital … must consider in wake of another tragic neuromuscular blocker event.

1731. Back to basics: preventing surgical site infections. | PSNet
      psnet.ahrq.gov/issue/back-basics-preventing-surgical-site-infections
      March 17, 2021 - August 16, 2023 Using potentially preventable severe maternal morbidity to monitor hospital … November 9, 2022 Root cause analysis of reported patient falls in ORs in the Veterans … February 6, 2019 Advances in perioperative quality and safety. … June 13, 2018 Innovation in safety, and safety in innovation.

1732. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - Complications (28) Delirium (4) Nosocomial Infections (3) Patient Falls … Clinic or Office (24) Home Care (4) Outpatient Pharmacy (3) Hospitals … (174) Children's Hospitals (3) General Hospitals (103) Emergency … (37) Labor and Delivery (6) Operating Room (28) Specialty Hospitals … his mid-50s presented to the hospital with a persistent headache after a sledding injury.

1733. Gossypiboma: tales of lost sponges and lessons learned. | PSNet
      psnet.ahrq.gov/issue/gossypiboma-tales-lost-sponges-and-lessons-learned
      March 24, 2021 - error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths … March 3, 2011 Improving resident engagement in quality improvement and patient safety … November 21, 2021 Structural racism in behavioral health presentation and management. … May 17, 2023 Nurses' attitudes to a medical emergency team service in a teaching hospital … November 16, 2022 Reducing falls in hospitalized children and adolescents with cancer

1734. Back to basics: counting soft surgical goods. | PSNet
      psnet.ahrq.gov/issue/back-basics-counting-soft-surgical-goods
      March 17, 2021 - This commentary explores improvement efforts that focus on the role of teams in performing surgical … August 16, 2023 Using potentially preventable severe maternal morbidity to monitor hospital … November 9, 2022 Root cause analysis of reported patient falls in ORs in the Veterans … November 6, 2013 Thinking in three's: changing surgical patient safety practices in the … January 16, 2013 The lost sponge: patient safety in the operating room.

1735. Patient factors associated with new prescribing of potentially inappropriate medications in multimorbid US older adults using multiple medications. | PSNet
      psnet.ahrq.gov/issue/patient-factors-associated-new-prescribing-potentially-inappropriate-medications-multimorbid
      August 18, 2021 - August 18, 2021 Assessment of requests for medication-related follow-up after hospital … discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective … older people prior to a potentially preventable drug-related hospital admission. … older adults with a history of falls: a qualitative study. … June 22, 2009 Risk of medication errors at hospital discharge and barriers to problem

1736. ED overcrowding is associated with an increased frequency of medication errors. | PSNet
      psnet.ahrq.gov/issue/ed-overcrowding-associated-increased-frequency-medication-errors
      August 20, 2018 - The Institute of Medicine found that hospital-based emergency care was "at the breaking point" in a seminal … Initiative to deprescribe high-risk drugs for older adults presenting to the emergency department after falls … hospital practice: factors associated with turnover, outcomes, and patient safety. … November 16, 2022 Families as partners in hospital error and adverse event surveillance … adverse events in older patients admitted to hospital: a retrospective cohort study.

1737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846171/psn-pdf
      July 26, 2022 - Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. … the Acute Care Setting Delirium is the most common psychiatric disorder in the hospital setting. … every US hospital. … Take-Home Points NGT placement is a common procedure in the hospital setting and is safe in most cases … I-DECIDED®—A decision tool for assessment and management of invasive devices in the hospital setting

1738. Evaluation of outpatient computerized physician medication order entry systems: a systematic review. | PSNet
      psnet.ahrq.gov/issue/evaluation-outpatient-computerized-physician-medication-order-entry-systems-systematic-review
      February 14, 2024 - The authors reviewed the literature on computerized physician order entry (CPOE) in the outpatient … October 18, 2023 Electronic health record-based prediction models for in-hospital adverse … A laboratory experiment and field study in cardiac rehabilitation. … April 12, 2017 Potentially inappropriate medications and their effect on falls during … hospital admission.

1739. Family conferences to facilitate deprescribing in older outpatients with frailty and with polypharmacy: the COFRAIL cluster randomized trial. | PSNet
      psnet.ahrq.gov/issue/family-conferences-facilitate-deprescribing-older-outpatients-frailty-and-polypharmacy
      July 29, 2020 - July 29, 2020 Inappropriate hospital admission as a risk factor for the subsequent development … care units and hospital emergency services. … older adults with a history of falls: a qualitative study. … primary care and its association with hospital admission: longitudinal study. … June 28, 2017 The effect of medication reconciliation in elderly patients at hospital

1740. Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
      January 01, 2020 - adverse events including falls, central nervous system depression and respiratory depression – Due … Needed/Quality Improvement Approach (2) • New, inexperienced nurses are often placed on night shift – Hospitals … experienced nurses and supervisors to provide oversight • Strong orientation and onboarding to both the hospital … most community hospitals, there may be few physicians or pharmacy staff available to inpatient units … Sleep Deprivation and Error in Nurses who Work the Night Shift.