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psnet.ahrq.gov/issue/self-reported-gaps-care-coordination-and-preventable-adverse-outcomes-among-older-adults
July 06, 2022 - Study
Self-reported gaps in care coordination and preventable adverse outcomes among … Self‐reported gaps in care coordination and preventable adverse outcomes among older adults receiving … visits or hospital admissions). … care coordination reported in a national study of older US adults. … Strategies to improve the patient safety outcome indicator: preventing or reducing falls
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psnet.ahrq.gov/issue/challenges-and-opportunities-improving-patient-safety-through-human-factors-and-systems
September 11, 2019 - the Same Author(s)
Information flow during pediatric trauma care transitions: things falling … and outcomes in two handoff processes. … February 10, 2015
Preparing your hospital for compliance with The Joint Commission's … July 16, 2014
Spreading human factors expertise in healthcare: untangling the knots in … and messages in a noisy environment.
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-reducing-risk-harm
November 15, 2011 - in this setting, including structured communication tools and analysis of failures to develop safer … a children's hospital. … February 1, 2023
Usability of a human factors-based clinical decision support in the … August 20, 2018
Mandating limits on workload, duty, and speed in radiology. … September 9, 2011
Primary care–relevant interventions to prevent falling in older adults
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - Appreciate the unique challenges posed by transition in care from the hospital to outpatient physician … Even if the transfer of care is done poorly, the patient still is in the hospital and is surrounded by … Furthermore, hospital-based care teams and primary care physicians often exist in different health care … Emergency department visits by persons recently discharged from U.S. hospitals. … Related Resources
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/39946/psn-pdf
October 20, 2023 - October 20, 2023
Okemos, MI: Michigan Health & Hospital Association. … The achievements noted in the 2022-2023 data review include reduction both fall
and blood- or blood-product
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psnet.ahrq.gov/issue/nature-reported-safety-events-related-care-coordination-operating-room-setting-tertiary
May 11, 2022 - The nature of reported safety events related to care coordination in the operating room setting in a … In the perioperative setting of one hospital, insufficient handoffs were the most common event type … The nature of reported safety events related to care coordination in the operating room setting in a … Download Citation
Related Resources From the Same Author(s)
Patient falls … September 13, 2017
Factors related to serious safety events in a children's hospital
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psnet.ahrq.gov/issue/identifying-boundary-spanning-reporter-roles-patient-safety-events
December 07, 2022 - Identifying boundary spanning reporter roles in patient safety events. … Identifying boundary spanning reporter roles in patient safety events. … review of root cause analyses of falls leading to adverse events. … March 13, 2024
Middle manager responses to hospital co-workers' unprofessional behaviours … among various hospital-based healthcare professionals and trainees in a simulated patient room.
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - There is tremendous variation in hospital care, with low-risk cesarean rates ranging from 2.4% to 36.5% … across hospitals. 4 These variations are attributed to hospital and provider factors as well as to … across states, ranging from roughly 18% to 30.9% in 2021. 5,6 In 2016, 24 hospitals (the first of three … ) participated in the program. 9 Compared with hospitals that were not participating in, or exposed … July 23, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/issue/omissions-care-nursing-home-settings-narrative-review
November 18, 2020 - Omissions of care in nursing home settings: a narrative review. … omissions of care, and identified nineteen event types, with the most common being all-cause mortality, falls … Omissions of care in nursing home settings: a narrative review. … March 3, 2021
A multi-hospital before–after observational study using a point-prevalence … August 5, 2015
Medication safety in a psychiatric hospital.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - 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 team … If users program an infusion rate that falls outside of approved ranges (i.e., over-doses or under-doses … Patient safety and computerized medication ordering at Brigham and Women's Hospital.
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psnet.ahrq.gov/issue/standardisation-handoffs-large-academic-paediatric-emergency-department-using-i-pass
October 21, 2020 - The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. … hospital. … in patient safety. … March 8, 2023
Using human factors and ergonomics principles to prevent inpatient falls … December 22, 2021
Results and lessons from a hospital-wide initiative incentivised by
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psnet.ahrq.gov/issue/patients-perception-types-errors-palliative-care-results-qualitative-interview-study
December 04, 2016 - Adverse events in palliative care differ from those in other environments. … December 4, 2016
Situation awareness errors in anesthesia and critical care in 200 cases … a multistate hospital network--13 academic medical centers, April-June 2020. … April 10, 2019
Adequacy of information transferred at resident sign-out (in-hospital … December 4, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/issue/impacts-using-community-health-volunteers-coach-medication-safety-behaviors-among-rural
September 15, 2011 - among elderly patients with chronic illness in a rural area. … 2020
Barriers and facilitators to implementing interventions for reducing avoidable hospital … December 17, 2014
Applying root cause analysis to improve patient safety: decreasing falls … in postpartum women. … March 23, 2011
Out-of-hospital medication errors: a 6-year analysis of the national poison
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psnet.ahrq.gov/issue/espen-guideline-hospital-nutrition
February 17, 2015 - ESPEN guideline on hospital nutrition. … Mistakes in hospital dietary services can contribute to allergic reactions and patient malnourishment … ESPEN guideline on hospital nutrition. … acute-care hospitals: 2022 Update. … February 13, 2008
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See More About The Topic
Hospitals
Allied
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psnet.ahrq.gov/issue/insurers-stop-paying-care-linked-errors
January 18, 2023 - October 3, 2017
CA sitting on millions in hospital fines. … May 27, 2009
Medication errors in family practice, in hospitals and after discharge from … the hospital: an ethical analysis. … May 16, 2008
Many Mass. hospitals will pay for errors. … Patients
General Internal Medicine
Hospital Medicine
View More
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psnet.ahrq.gov/issue/moving-beyond-misuse-and-diversion-urgent-need-consider-role-iatrogenic-addiction-current
July 18, 2012 - Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in … Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the … A substantial number of drug deaths in the United States have been associated with inadvertent overdose … March 3, 2011
Errors and discrepancies in the administration of intravenous infusions … July 2, 2014
Cost of inpatient falls and cost-benefit analysis of implementation of an
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psnet.ahrq.gov/issue/nursing-home-patient-safety-culture-perceptions-among-licensed-practical-nurses
February 17, 2021 - and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working … in other settings. … Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in … fall prevention in a nursing home. … December 9, 2020
Expanding frontiers of risk management: care safety in nursing home
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psnet.ahrq.gov/issue/situation-background-assessment-and-recommendation-guided-huddles-improve-communication-and
September 23, 2020 - In an effort to improve communication in an urban emergency department, nurse practitioners and registered … a multistate hospital network--13 academic medical centers, April-June 2020. … October 3, 2012
Overtreatment in the United States. … Diagnostic Safety in the Emergency Department. … June 13, 2018
In situ simulation: detection of safety threats and teamwork training in
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psnet.ahrq.gov/issue/department-anesthesiology-skilled-peer-support-program-outcomes-second-victim-perceptions
April 12, 2011 - Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in … fall prevention in a nursing home. … Perspectives on Safety
Interview
In … 2024
Peer support and second victim programs for anesthesia professionals involved in … November 14, 2011
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See More About The Topic
Hospitals
Operating
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psnet.ahrq.gov/issue/safety-climate-associated-adverse-events-nursing-homes-national-va-study
September 08, 2021 - Study
Safety climate associated with adverse events in nursing homes: a national … Safety climate associated with adverse events in nursing homes: a national VA study. … survey found that supervisor commitment to safety was associated with lower rates of major injuries from falls … and that environmental safety was associated with lower rates of pressure ulcers, major injuries from falls … Safety climate associated with adverse events in nursing homes: a national VA study.