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1781. Should patients have a role in patient safety? A safety engineering view. | PSNet
      psnet.ahrq.gov/issue/should-patients-have-role-patient-safety-safety-engineering-view
      June 10, 2009 - Commentary Should patients have a role in patient safety? … Should patients have a role in patient safety? A safety engineering view. … Should patients have a role in patient safety? A safety engineering view. … and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. … July 1, 2020 Diagnostic Error in Medicine.

1782. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet
      psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
      March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause … review of root cause analyses of falls leading to adverse events. … 6, 2022 Root cause analysis to identify contributing factors for the development of hospital … August 22, 2016 Measuring patient safety in the emergency department. … November 13, 2013 Improving handoffs in the emergency department.

1783. Therapeutic errors involving adults in the community setting: nature, causes and outcomes. | PSNet
      psnet.ahrq.gov/issue/therapeutic-errors-involving-adults-community-setting-nature-causes-and-outcomes
      May 24, 2009 - residents in Victoria, Australia. … hospital practice: factors associated with turnover, outcomes, and patient safety. … July 24, 2013 The effect of medication reconciliation in elderly patients at hospital … March 4, 2011 The patient who falls: "It's always a trade-off." … long-term care facilities in Germany.

1784. Privacy Gone Awry | PSNet
      psnet.ahrq.gov/web-mm/privacy-gone-awry
      February 24, 2011 - In preparation for an upcoming JCAHO inspection, the small community hospital (which had suffered from … monitoring device, we should have an alarm ( 19 ) for automatically indicating when that parameter falls … would inconvenience the patient's family and represent a potential revenue loss for the surgeon and the hospital … Cuff May 1, 2003 View More See More About The Topic General Hospitals … Children's Hospitals Health Care Providers Pediatrics Surgery View More

1785. Sterile compounding: clinical, legal, and regulatory implications for patient safety. | PSNet
      psnet.ahrq.gov/issue/sterile-compounding-clinical-legal-and-regulatory-implications-patient-safety
      March 20, 2024 - 2013, resulting in more than 60 deaths. … May 15, 2024 Reduced postdischarge incidents after implementation of a hospital-to-home … December 11, 2024 Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based … July 22, 2020 Reducing falls with a safety spotter program. … January 23, 2019 Community-acquired and hospital-acquired medication harm among older

1786. Devastatingly human: an analysis of registered nurses' medication error accounts. | PSNet
      psnet.ahrq.gov/issue/devastatingly-human-analysis-registered-nurses-medication-error-accounts
      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. … September 27, 2016 Role of relatives of ethnic minority patients in patient safety in … hospital care: a qualitative study. … are in jeopardy.

1787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849660/psn-pdf
      May 31, 2023 - Errors in care and adverse events associated with health literacy include mistakes in diabetes management … for children;3  incorrect use of inhalers and aerosol medications;4 falls; delays in receiving treatment … generic (e.g., Health Literate Health Care Organization-106 or the Health Literacy Environment of Hospitals … Have processes in place to review materials with patients. … high risk situation such as when patients are prescribed medications or are discharged from the hospital

1788. Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study. | PSNet
      psnet.ahrq.gov/issue/antimicrobial-residual-drug-error-intensive-care-unit-single-blinded-prospective
      November 21, 2021 - As with all medications, delays in or underdosing of  antimicrobials can result in unnecessarily long … hospital stays. … May 18, 2022 Clinical impact and economic burden of hospital-acquired conditions following … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls … View More See More About The Topic Intensive Care Units Critical Care Nursing Hospital

1789. Diagnostic Errors Case Studies | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
      August 10, 2025 - An elderly man had iron deficiency anemia with progressively falling … The patient was admitted to the hospital with gastrointestinal symptoms and diagnosed with cholecystitis … ED for a third time, where has was evaluated and involuntarily admitted to an inpatient psychiatric hospital … Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from … Linkedin Copy URL An elderly man had iron deficiency anemia with progressively falling

1790. The prevalence and impact of potentially inappropriate prescribing among older persons in primary care settings: multilevel meta-analysis. | PSNet
      psnet.ahrq.gov/issue/prevalence-and-impact-potentially-inappropriate-prescribing-among-older-persons-primary-care
      July 24, 2019 - patient safety and reducing medical errors in hospital settings: a narrative review. … June 22, 2009 Reduction in hospital-wide clinical laboratory specimen identification … drug-related hospital admissions? … older adults with a history of falls: a qualitative study. … September 29, 2017 Mistakes We Make in Dialysis.

1791. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47847/psn-pdf
      July 10, 2024 - July 10, 2024 California Hospital Patient Safety Organization: Sacramento, CA; 2024. … Sections of the report include high-level review of falls and inequities, medication safety issues, syphilis

1792. There is a vulnerable group we must not leave behind in our response to COVID-19: people who are dependent on illicit drugs. | PSNet
      psnet.ahrq.gov/issue/there-vulnerable-group-we-must-not-leave-behind-our-response-covid-19-people-who-are
      October 05, 2022 - Newspaper/Magazine Article There is a vulnerable group we must not leave behind in … August 25, 2021 Interventions to prevent falls in older adults: updated evidence report … effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital … in patients with polypharmacy. … July 29, 2020 Special report: COVID deepens the other opioid crisis - a shortage of hospital

1793. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33766/psn-pdf
      May 01, 2014 - To be compared from one hospital to another in particular, or even from one ward to another in the same … We have much experience with monitoring this tool and it has been used in more than 5000 hospitals worldwide … Some of the data for US hospitals were recently published in the American Journal of Infection Control … , and it's clear that many hospitals have succeeded in applying system change; for example, making sure … to generalize from the hand hygiene experience to let's say trying to decrease falls or medication

1794. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
      August 01, 2014 - credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hospital … Necrotizing Fasciitis A 49-year-old previously healthy man presented to the emergency department (ED) after falling … of erysipelas Since then, numerous terms have been applied to this condition—phagedena gangrenosum, hospital … Investigation upon the nature, causes, and treatment of hospital gangrene, as it prevailed in the confederate … one study, they were present in only 43% of patients with NF Fever may not be present In one review,

1795. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? | PSNet
      psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and
      June 16, 2021 - patient safety in the NHS. … July 3, 2014 Do falls and other safety issues occur more often during handovers when … June 29, 2022 Why do hospital prescribers continue antibiotics when it is safe to stop … October 15, 2014 Patient involvement in medication safety in hospital: an exploratory … July 16, 2014 Speaking up for patient safety by hospital-based health care professionals

1796. Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study. | PSNet
      psnet.ahrq.gov/issue/strategies-safe-interhospital-transfer-intubated-patient-or-where-readiness-intubation-needed
      July 31, 2013 - November 2, 2022 Teamwork is associated with reduced hospital staff burnout at military … May 31, 2023 Patient Safety Innovations Preventing Falls … February 6, 2019 Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired … catheter-associated urinary tract infections in intensive care units. … May 25, 2011 Worries and concerns experienced by nurse specialists during inter-hospital

1797. Postdischarge adverse events among neonates admitted to the neonatal intensive care unit. | PSNet
      psnet.ahrq.gov/issue/postdischarge-adverse-events-among-neonates-admitted-neonatal-intensive-care-unit
      October 05, 2022 - including procedural complications and adverse drug events) and subsequent emergency department visits or hospital … Post-discharge adverse events among African American and Caucasian patients of an urban community hospital … July 31, 2013 Validation of the second victim experience and support tool-revised in … review of root cause analyses of falls leading to adverse events. … intensive care unit: the behavioral impact of in situ simulation.

1798. Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. | PSNet
      psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
      November 15, 2023 - Use By Other Organizations The Hospital at Home program has been adopted by 41 hospitals, health … At Home program, which expanded on the “Hospitals Without Walls” program implemented in response to … In addition, hospitalized seniors are at risk of falls, fractures, and medical/medication errors. 2 … complications such as delirium and falls), urinary catheters, or chemical or physical restraints and … Hospital at home versus in-patient hospital care.

1799. Patient-centered prescription opioid tapering in community outpatients with chronic pain. | PSNet
      psnet.ahrq.gov/issue/patient-centered-prescription-opioid-tapering-community-outpatients-chronic-pain
      May 17, 2017 - Emerging Classic Patient-centered prescription opioid tapering in … Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain. … a multistate hospital network--13 academic medical centers, April-June 2020. … January 29, 2020 Unsafe care in residential settings for older adults. … older adults with a history of falls: a qualitative study.

1800. Mismanagement of Delirium | PSNet
      psnet.ahrq.gov/web-mm/mismanagement-delirium
      February 13, 2014 - By history, this patient exhibited features of parkinsonism (shuffling gait and falls), disturbed nighttime … Instead, the patient was transferred to the hospital emergency department, spending an entire night in … impairment Advancing age (> 65 years) History of delirium, stroke, neurological disease, falls … February 13, 2014 Families as partners in hospital error and adverse event surveillance … Worst Headache July 1, 2004 View More See More About The Topic Hospitals