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psnet.ahrq.gov/issue/improving-medication-administration-safety-community-hospital-setting-using-lean-methodology
September 23, 2020 - Commentary
Improving medication administration safety in a community hospital setting … Improving medication administration safety in a community hospital setting using Lean methodology. … This commentary discusses how one hospital applied Lean methodology in an interdisciplinary effort … Improving medication administration safety in a community hospital setting using Lean methodology. … July 3, 2013
Utilizing quality improvement methods to prevent falls and injury from falls
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psnet.ahrq.gov/issue/revitalizing-established-rapid-response-team
September 23, 2020 - a multistate hospital network--13 academic medical centers, April-June 2020. … July 5, 2017
Cost of inpatient falls and cost-benefit analysis of implementation of an … November 16, 2022
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls … March 26, 2008
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Hospitals
Nurses
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psnet.ahrq.gov/issue/keeping-each-patient-safe
September 21, 2005 - These include protecting patients from hospital-acquired infection, minimizing falls and confusion, and … The organization was recognized for this work with the John Eisenberg award in 2004 . … July 19, 2023
Serious Reportable Events in Massachusetts. … October 24, 2018
Fall Prevention in Hospitals Training Program. … See More About The Topic
Health Care Providers
Nosocomial Infections
Patient Falls
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psnet.ahrq.gov/node/72554/psn-pdf
December 09, 2020 - Fall prevention implementation strategies in use at 60
United States hospitals: a descriptive study. … Fall prevention implementation strategies in use at 60 United States
hospitals: a descriptive study. … https://psnet.ahrq.gov/issue/fall-prevention-implementation-strategies-use-60-united-states-hospitals … in the United States. … inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
https://psnet.ahrq.gov/primer/falls
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psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk-management-tool
June 19, 2024 - Related Resources
Patient Safety Innovations
Preventing Falls … in ORs in the Veterans Health Administration. … July 16, 2015
Effects of an intervention to increase bed alarm use to prevent falls in … July 21, 2010
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Hospitals
Facility … and Group Administrators
Risk Managers
Hospital Medicine
Nurse Care
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psnet.ahrq.gov/issue/improving-communication-diagnostic-uncertainty-families-hospitalized-children
December 23, 2020 - December 23, 2020
Uncertain diagnoses in a children's hospital: patient characteristics … January 22, 2025
Reducing falls in hospitalized children and adolescents with cancer … Study
The Stoplight Mobility Alert System for safety and prevention of falls … August 7, 2019
Parents' perspectives on "keeping their children safe" in the hospital … Hospitals
Pediatrics
Clinical Misdiagnosis
Provider-Patient Communication
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psnet.ahrq.gov/issue/preventable-and-mitigable-adverse-events-cancer-care-measuring-risk-and-harm-across-continuum
July 19, 2017 - Adverse events included medication errors and hospital-acquired conditions , such as pressure ulcers … and falls. … : do patients know something that hospitals do not? … February 1, 2012
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Hospitals
Health … Care Providers
Medical Oncology
Chemotherapeutic Agents
Patient Falls
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psnet.ahrq.gov/issue/medical-errors-kill-thousands-people-each-year-are-hospitals-getting-any-safer
June 17, 2020 - But are hospitals getting any safer? … The semi-annual Leapfrog Hospital Safety Grades are recognized across the industry as a tool for highlighting … article shares one organization’s work to improve core safety activities related to medication safety, falls … lure patients back in COVID-19 era. … September 28, 2022
CMS proposal to suppress hospital safety data angers advocates — agency
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psnet.ahrq.gov/issue/preventing-newborn-falls-and-drops
October 10, 2018 - Newspaper/Magazine Article
Preventing newborn falls and drops. … while preserving rooming-in on a mother-baby unit. … January 29, 2020
What's in a name? … July 16, 2019
Mother claims hospital error kept her from newborn daughter. … June 13, 2011
Safety shortcomings spotted in Sunrise catheter case.
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psnet.ahrq.gov/node/41298/psn-pdf
November 27, 2012 - Patient safety culture and the association with safe
resident care in nursing homes. … Patient safety culture and the association with safe resident care in
nursing homes. … a structure (safety culture), a process (use of physical restraints), and an
outcome (incidence of falls … statistically significant association between higher
safety culture scores, lower use of restraints, and fewer falls … https://psnet.ahrq.gov/primer/culture-safety
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
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psnet.ahrq.gov/issue/staffing-teamwork-and-scope-practice-analysis-association-patient-safety-context
September 20, 2017 - July 11, 2018
ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical … October 28, 2020
ASHP national survey of pharmacy practice in hospital settings: prescribing … June 5, 2019
Influence of unit-level staffing on medication errors and falls in military … hospitals. … care hospital units.
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psnet.ahrq.gov/issue/measured-response-identified-suicide-risk-and-violence-what-you-need-know-about-psychiatric
January 30, 2019 - April 12, 2023
Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency … May 11, 2016
Provider-patient communication and hospital ratings: perceived gaps and … December 16, 2020
Safety events in children's hospitals during the COVID-19 pandemic. … March 18, 2015
Reducing falls and fall-related injuries in mental health: a 1-year multihospital … falls collaborative.
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psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis
August 04, 2021 - mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … September 7, 2022
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … and Quality of Long Term Care
September 1, 2011
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/fable-reality-parkland-hospital-impact-evidence-based-design-strategies-patient-safety
September 09, 2020 - In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable … to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls … a VA hospital: design and outcomes. … May 31, 2023
Patient Safety Innovations
Preventing Falls … February 8, 2012
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General Hospitals
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psnet.ahrq.gov/issue/field-guide-collaborative-care-implementing-future-health-care
March 09, 2018 - Resources
Perspective
The Ongoing Journey to Prevent Patient Falls … with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
December 18, 2024 … October 19, 2016
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help … October 5, 2011
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Hospitals
Health … Care Providers
Health Care Executives and Administrators
Patients
Hospital Medicine
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psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
January 13, 2021 - Citation Text:
Cost of medication-related problems at a university hospital. … older adults with a history of falls: a qualitative study. … review of root cause analyses of falls leading to adverse events. … January 30, 2019
Adverse drug events and medication problems in "Hospital at Home" patients … April 27, 2010
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Hospitals
Health
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psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis
June 21, 2017 - The most common incidents were falls and delayed response to clinical deterioration. … November 21, 2012
Root cause analysis of reported patient falls in ORs in the Veterans … March 25, 2020
Suicide and suicide attempts on hospital grounds and clinic areas. … December 4, 2016
Inpatient suicide and suicide attempts in Veterans Affairs hospitals … January 18, 2011
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Hospitals
Allied
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psnet.ahrq.gov/issue/nursing-practice-hospitalised-older-people-safety-and-harm
April 24, 2018 - This review found that restraint use and limiting mobility to prevent falls can result in functional … hospital error and adverse event surveillance. … December 8, 2021
Do falls and other safety issues occur more often during handovers when … August 7, 2019
Fall prevention in hospitals: an integrative review. … July 8, 2009
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Hospitals
Nurses
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psnet.ahrq.gov/issue/lehigh-valley-hospital-engaging-patients-and-families
January 04, 2017 - Lehigh Valley Hospital: engaging patients and families. … Lehigh Valley Hospital: engaging patients and families. … Resources
Perspective
The Ongoing Journey to Prevent Patient Falls … with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
December 18, 2024 … Patient Safety
March 1, 2007
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Hospitals
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - If you try and treat those common risk factors, then you will mitigate those harms in hospitals. … Our prior approach to falls was, “if we keep them in bed they won’t fall.” … We don’t want patients falling and breaking a bone while in the hospital under nurse supervision. … If a patient who is hospitalized for something, and is already quite debilitated, falls in the hospital … HW : SCL Health is made up of eight hospitals and over one hundred ambulatory sites in Colorado and Montana