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psnet.ahrq.gov/node/46910/psn-pdf
January 23, 2019 - A qualitative
study of a large-scale exercise in seeking to measure for
improvement, not blame. … A qualitative study of
a large-scale exercise in seeking to measure for improvement, not blame. … Kingdom, the NHS Safety Thermometer, which
measured incidence of pressure ulcers, harm from falls, … preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
https://psnet.ahrq.gov/primer/falls … https://psnet.ahrq.gov/issue/toolkit-reducing-cauti-hospitals
https://psnet.ahrq.gov/issue/preventability-hospital-acquired-venous-thromboembolism
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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/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
View More
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psnet.ahrq.gov/node/50701/psn-pdf
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
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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/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
View More
See More About The Topic
Hospitals
Health … Care Providers
Health Care Executives and Administrators
Patients
Hospital Medicine
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psnet.ahrq.gov/issue/sponges-tools-and-more-left-inside-washington-hospital-patients
October 30, 2013 - This audio news segment reports on retained surgical items along with strategies hospitals in Washington … Cite
Related Resources From the Same Author(s)
To reduce patient falls … , hospitals try alarms, more nurses. … August 13, 2014
Hospitals put pharmacists in the ER to cut medication errors. … August 17, 2011
Hospital-acquired infections.
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psnet.ahrq.gov/node/43499/psn-pdf
September 03, 2014 - Older folks in hospitals: the contributing factors and
recommendations for incident prevention. … Older folks in hospitals: the contributing factors and
recommendations for incident prevention. … https://psnet.ahrq.gov/issue/older-folks-hospitals-contributing-factors-and-recommendations-incident- … prevention
This retrospective review of incident reports at a tertiary care hospital revealed that … errors related to falls,
medication management, and clinical care were the most common adverse events
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psnet.ahrq.gov/issue/nurses-experience-decision-making-processes-missed-nursing-care-qualitative-study
May 11, 2022 - This qualitative study conducted focus groups with 28 registered nurses working in different hospital … hospital: a cross-sectional survey. … May 11, 2022
Medication dose calculation errors and other numeracy mishaps in hospitals … November 10, 2021
Clinical deterioration and hospital‐acquired complications in adult … September 7, 2011
View More
See More About The Topic
Hospitals
Nurse
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psnet.ahrq.gov/node/73660/psn-pdf
September 01, 2021 - Hospital inpatient falls across clinical departments. … Hospital inpatient falls across clinical departments. … https://psnet.ahrq.gov/issue/hospital-inpatient-falls-across-clinical-departments
Patient falls resulting … In this analysis of falls within one hospital,
rates and trends varied across six clinical departments … The highest rate of falls was seen in rehabilitation
and internal medicine, and the lowest rate in orthopedic
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psnet.ahrq.gov/node/836776/psn-pdf
March 23, 2022 - Potentially inappropriate medications and their effect on
falls during hospital admission. … Potentially inappropriate medications and their effect on
falls during hospital admission. … https://psnet.ahrq.gov/issue/potentially-inappropriate-medications-and-their-effect-falls-during-hospital … This study assessed the impact of potentially inappropriate medications
(PIM) on falls in older adults … https://psnet.ahrq.gov/issue/potentially-inappropriate-medications-and-their-effect-falls-during-hospital-admission
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psnet.ahrq.gov/node/866280/psn-pdf
July 10, 2024 - Visitor restrictions during the COVID-19 pandemic and
increased falls with harm at a Canadian hospital … Visitor restrictions during the COVID-19 pandemic and increased
falls with harm at a Canadian hospital … pandemic and falls with harm at one
Canadian hospital. … https://psnet.ahrq.gov/issue/visitor-restrictions-during-covid-19-pandemic-and-increased-falls-harm-canadian-hospital … https://psnet.ahrq.gov/issue/visitor-restrictions-during-covid-19-pandemic-and-increased-falls-harm-canadian-hospital
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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/node/860380/psn-pdf
January 10, 2024 - Validity of 16 AHRQ Patient Safety Indicators to identify
in-hospital complications: a medical record … review across
nine Swiss hospitals. … Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital
complications: a medical record … This retrospective study examined the performance of 16 PSIs across nine
hospitals in Switzerland (where … The authors attributed low
positive predictive value (PPV) in three of the PSIs (pressure injury, falls
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psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen
June 16, 2021 - Citation Text:
Hospitals look to computers to predict patient emergencies before they happen. … This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence … October 23, 2019
Health systems and hospitals in pursuit of high reliability. … May 1, 2019
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. … Acute Hospital Care Units
April 26, 2023
Algorithm that detects sepsis cut
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psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
November 15, 2023 - June 16, 2019
In-hospital sequelae of injurious falls in 24 medical/surgical units in … four hospitals in the United States. … January 25, 2017
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 … June 27, 2011
View More
See More About The Topic
Hospitals
Health Care … Providers
Medicine
Indwelling Tubes and Catheters
Patient Falls
View More
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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
View More
See More About The Topic
General Hospitals
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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
View More
See More About The Topic
Hospitals
Health
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psnet.ahrq.gov/node/47858/psn-pdf
July 10, 2019 - Modification of potentially inappropriate prescribing
following fall-related hospitalizations in older … Modification of potentially inappropriate prescribing following fall-
related hospitalizations in older … This
study of a large sample of elderly patients in Ireland found that they were frequently prescribed … medications
that increased their risk of falling, and deprescribing was rare after a fall-related hospitalization … deprescribing-simple-method-reducing-polypharmacy
https://psnet.ahrq.gov/issue/medicines-related-harm-elderly-post-hospital-discharge
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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.