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psnet.ahrq.gov/issue/neglected-barrier-medication-use-systematic-review-difficulties-associated-opening-medication
February 16, 2022 - Resources From the Same Author(s)
Performance of a trigger tool for detecting drug-related hospital … the hospital setting: a systematic review. … March 30, 2022
Potentially inappropriate medications and their effect on falls during … hospital admission. … effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital
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psnet.ahrq.gov/issue/outcomes-quality-improvement-project-educating-nurses-medication-administration-and-errors
April 24, 2018 - Outcomes of a quality improvement project for educating nurses on medication administration and errors in … A recent AHRQ WebM&M commentary discusses medication safety in nursing homes. … hospital error and adverse event surveillance. … December 19, 2018
Sitters as a patient safety strategy to reduce hospital falls: a systematic … a multistate hospital network--13 academic medical centers, April-June 2020.
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psnet.ahrq.gov/issue/effect-distractions-operative-performance-and-ability-multitask-case-deliberate-practice
September 15, 2010 - March 12, 2025
Innovative approaches to analysing aged care falls incident data: International … scale and nature of harm to patients in hospital. … multistate hospital network--13 academic medical centers, April-June 2020. … hospital mortality. … surgery: tracking all failures in the pediatric cardiac operating room.
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psnet.ahrq.gov/issue/interventions-improve-safe-and-effective-medicines-use-consumers-overview-systematic-reviews
July 19, 2023 - hospital practice: factors associated with turnover, outcomes, and patient safety. … July 19, 2023
Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022
Families as partners in hospital error and adverse event surveillance … of patients with communication disabilities in hospital. … 27, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/issue/nurse-managers-leadership-patient-safety-and-quality-care-systematic-review
September 09, 2020 - effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital … in patients with polypharmacy. … June 12, 2019
From fable to reality at Parkland Hospital: the impact of evidence-based … Improving Diagnostic Safety and Quality
April 26, 2023
Do falls … Workplace verbal abuse, nurse-reported quality of care, and patient safety outcomes among early-career hospital
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psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
May 01, 2017 - Multi-use Website
Pressure Injury Prevention in Hospitals Training Program. … Citation Text:
Pressure Injury Prevention in Hospitals Training Program. … Pressure ulcers are a common hospital-acquired condition that can lead to patient harm . … Hospitals Training Program. … March 7, 2018
Fall Prevention in Hospitals Training Program.
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psnet.ahrq.gov/issue/avoidable-mistakes-rise-despite-hospital-efforts
September 27, 2016 - Citation Text:
Avoidable mistakes rise despite hospital efforts. Colliver V. … December 23, 2012
Never events: Utah hospitals saw nearly 60 serious errors in 2007. … July 23, 2008
Hospitals to tear up bills for medical mistakes. … February 13, 2008
Many Mass. hospitals will pay for errors. … General Internal Medicine
Hospital Medicine
Surgery
View More
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psnet.ahrq.gov/issue/bad-hospital-design-making-us-sicker
March 30, 2016 - Implementing design changes in care environments can improve patient safety. … March 30, 2016
Reducing preventable harm in hospitals. … February 12, 2016
A night in the hospital, from both ends of the stethoscope. … September 27, 2016
Hospitals target risks of color wristbands. … June 22, 2011
Never events: Utah hospitals saw nearly 60 serious errors in 2007.
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - is not unusual: in acute care hospitals, pressure ulcer incidence after hip
fracture ranges from 36.1% … risk factors contribute to the development of pressure ulcers in the hospital, many of which occur in … Changes in CMS
reimbursement (not paying for pressure ulcers that develop in the hospital) are based … Not all pressure ulcers are avoidable, but every pressure ulcer occurring in hospitals today should provide … What was their mobility and functional status prior to the fall, including any prior falls or hospitalizations
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psnet.ahrq.gov/node/35009/psn-pdf
May 27, 2011 - guidelines for administering
psychotropic medication to elderly patients at a tertiary care academic hospital … prescription of recommended doses, decreased prescription of nonrecommended drugs, and fewer
inpatient falls
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psnet.ahrq.gov/issue/what-medication-iatrogenic-risk-elderly-outpatients-chronic-pain
February 12, 2020 - English hospital organizations? … Initiative to deprescribe high-risk drugs for older adults presenting to the emergency department after falls … older people prior to a potentially preventable drug-related hospital admission. … July 20, 2022
Prevalence of potentially inappropriate prescribing in older people in … primary care and its association with hospital admission: longitudinal study.
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psnet.ahrq.gov/issue/functional-decline-associated-polypharmacy-and-potentially-inappropriate-medications
June 13, 2018 - Functional decline associated with polypharmacy and potentially inappropriate medications in … older adults with a history of falls: a qualitative study. … November 4, 2020
Hospital-acquired functional decline and clinical outcomes in older … March 2, 2022
Patient factors and hospital outcomes associated with atypical presentation … in hospitalized older adults with COVID-19 during the first surge of the pandemic.
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psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - September 1, 2010
Failure to rescue in neonatal care. … human factors methods to ensure appropriate infant identification and abduction prevention within the hospital … unique patient-safety challenge in obstetrics. … September 23, 2020
View More
Related Resources
Special Issue on Falls … in perinatal settings.
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psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety
May 13, 2020 - The investigators describe a system for classifying errors in clinical laboratories. … May 1, 2019
Report on the Safe Use of Pick Lists in Ambulatory Care Settings. … Doctors and Accountability in the Information Age. … May 13, 2015
Man falls off surgical table; St. Joseph's Hospital sued. … March 18, 2010
Patient safety and error reduction in surgical pathology.
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psnet.ahrq.gov/issue/teamwork-and-communication
February 06, 2019 - Articles in this special supplement outline tactics to improve communication including crew resource … December 15, 2010
Diagnostic error in acute care. … July 18, 2018
Medication assessment: one determinant of falls risk. … 2011
Outcomes of classroom-based team training interventions for multiprofessional hospital … ; assessment and impact on the first 32 facilities in the programme.
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psnet.ahrq.gov/issue/mix-wrong-route-administration-bladder-irrigation-intravenous-iv-infusions
March 27, 2005 - Related Resources From the Same Author(s)
National Center for Patient Safety Falls … December 12, 2012
Safety climate associated with adverse events in nursing homes: a national … a VA hospital: design and outcomes. … December 24, 2014
TIPS (Topics in Patient Safety). … April 16, 2018
VA Interprofessional Fellowship Program in Patient Safety.
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psnet.ahrq.gov/issue/support-and-recovery-strategies-second-victims
January 19, 2022 - Clinicians involved in medical errors can be psychologically affected by the experience and they can … January 19, 2022
Safety work and risk management as burdens of treatment in primary care … 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 … March 27, 2024
Creating a just culture in the perioperative setting.
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psnet.ahrq.gov/issue/value-library-and-information-services-patient-care-results-multisite-study
April 24, 2018 - Study
The value of library and information services in patient care: results of a … The value of library and information services in patient care: results of a multisite study. … The value of library and information services in patient care: results of a multisite study. … hospital error and adverse event surveillance. … April 24, 2018
Optimizing Pediatric Patient Safety in the Emergency Care Setting.
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psnet.ahrq.gov/issue/safety-culture-healthcare-review-concepts-dimensions-measures-and-progress
November 21, 2014 - Review
Safety culture in healthcare: a review of concepts, dimensions, measures and … Safety culture in healthcare: a review of concepts, dimensions, measures and progress. … Safety culture in healthcare: a review of concepts, dimensions, measures and progress. … November 21, 2014
Utilization of the Seniors Falls Investigation Methodology to identify … system-wide causes of falls in community-dwelling seniors.
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psnet.ahrq.gov/issue/trend-analysis-radiation-therapy-incidents-over-seven-years
December 20, 2023 - Related Resources From the Same Author(s)
Interventions to promote safety culture in … December 20, 2023
Overnight stay in the emergency department and mortality in older patients … Effect of sleep deprivation after a night shift duty on simulated crisis management by residents in … severe adverse events in the adult medical intensive care unit: a seven-year prospective study. … November 7, 2018
Mortality due to hospital-acquired infection after cardiac surgery.