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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/node/47901/psn-pdf
April 10, 2019 - A systematic review of falls in hospital for patients with
communication disability: highlighting an … A systematic review of falls in hospital for patients with communication
disability: Highlighting an … https://psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting … https://psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible … https://psnet.ahrq.gov/issue/systematic-review-falls-hospital-patients-communication-disability-highlighting-invisible
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psnet.ahrq.gov/node/40311/psn-pdf
March 23, 2011 - https://psnet.ahrq.gov/issue/association-shift-level-nurse-staffing-adverse-patient-events
In this study … conducted at military hospitals, greater nursing experience and skill mix was associated with a
lower … incidence of falls and medication errors. … association-shift-level-nurse-staffing-adverse-patient-events
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
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psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
August 24, 2022 - Emerging Classic
Assessment of nursing home reporting of major injury falls … Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare … This study compared falls with injury data self-reported by nursing homes against those identified in … July 20, 2022
Do crowdsourced hospital ratings coincide with Hospital Compare measures … awaiting long-term care in hospital.
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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/node/46261/psn-pdf
July 18, 2018 - issue/pilot-testing-fall-tips-tailoring-interventions-patient-safety-patient-centered-fall
Patient falls … In this study, researchers describe the implementation of an inpatient fall prevention toolkit at
two … hospitals. … pilot-testing-fall-tips-tailoring-interventions-patient-safety-patient-centered-fall
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial … implementing-fall-prevention-program
https://psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial
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psnet.ahrq.gov/issue/approaches-improving-patient-safety-integrated-care-scoping-review
May 18, 2022 - Most of the studies focused on decreasing risk of falls and/or medication errors, mostly in the home … The authors recommend future research focus on safety targets beyond falls and medication safety and … November 12, 2014
Avoidability of hospital deaths and association with hospital-wide … July 17, 2024
Clinical deterioration as a nurse sensitive indicator in the out-of-hospital … July 1, 2020
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Hospitals
Home Care
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psnet.ahrq.gov/issue/opioids-and-falls-risk-older-adults-narrative-review
January 12, 2022 - Review
Opioids and falls risk in older adults: a narrative review. … Opioids and falls risk in older adults: a narrative review. … Opioids and falls risk in older adults: a narrative review. … hospital admission. … April 13, 2022
Drug-drug interactions and prescription appropriateness at hospital discharge
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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/node/73396/psn-pdf
June 16, 2021 - The impact of the built environment on patient falls in
hospital rooms: an integrative review. … The impact of the built environment on patient falls in hospital rooms:
an integrative review. … https://psnet.ahrq.gov/issue/impact-built-environment-patient-falls-hospital-rooms-integrative-review … Decreasing inpatient falls requires improvements in both processes of care and the care environment … https://psnet.ahrq.gov/issue/impact-built-environment-patient-falls-hospital-rooms-integrative-review
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psnet.ahrq.gov/issue/using-orgahead-computational-modeling-program-improve-patient-care-unit-safety-and-quality
June 22, 2011 - hospital practice: factors associated with turnover, outcomes, and patient safety. … Related Resources
Patient Safety Innovations
Preventing Falls … February 10, 2021
Nursing care quality and adverse events in US hospitals. … September 26, 2016
Partnering to prevent falls: using a multimodal multidisciplinary … August 14, 2013
Falls prevention at Mayo Clinic Rochester: a path to quality care.
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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/patient-safety-initiative-hospital-executive-and-physician-leadership-strategies
November 27, 2018 - Toolkit
Patient Safety Initiative: Hospital Executive and Physician Leadership Strategies … Citation Text:
Patient Safety Initiative: Hospital Executive and Physician Leadership Strategies. … January 27, 2016
Toolkit for Reducing CAUTI in Hospitals. … December 9, 2015
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care … September 10, 2014
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Hospitals
Physicians
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psnet.ahrq.gov/issue/randomized-trial-multifactorial-strategy-prevent-serious-fall-injuries
August 04, 2021 - ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls … a multistate hospital network--13 academic medical centers, April-June 2020. … hospital practice: factors associated with turnover, outcomes, and patient safety. … hospital admission. … older adults with a history of falls: a qualitative study.
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psnet.ahrq.gov/issue/core-elements-hospital-diagnostic-excellence-dxex
April 26, 2023 - Multi-use Website
Core Elements of Hospital Diagnostic Excellence (DxEx). … Citation Text:
Core Elements of Hospital Diagnostic Excellence (DxEx). … March 7, 2018
Pressure Injury Prevention in Hospitals Training Program. … October 18, 2017
Preventing Falls With Injury. … January 15, 2014
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Hospitals
Medicine
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psnet.ahrq.gov/issue/mindful-path-nursing-accuracy-quasi-experimental-study-minimizing-medication-administration
March 03, 2019 - Nurses at an American hospital were trained in mindful thinking in an effort to reduce MAE. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls … medication administration in hospitals. … September 22, 2017
Errors in the administration of intravenous medications in hospital … March 11, 2011
Examining medication errors in a tertiary hospital.
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psnet.ahrq.gov/issue/organisational-strategies-implement-hospital-pressure-ulcer-prevention-programmes-findings
June 02, 2021 - Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment … They found that such strategies were not operationalized in a uniform manner across the hospitals and … Related Resources
Patient Safety Innovations
Preventing Falls … ulcers in a system of community hospitals. … March 7, 2018
Fall prevention in hospitals: an integrative review.
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psnet.ahrq.gov/issue/stoppstart-criteria-potentially-inappropriate-prescribing-older-people-version-3
January 12, 2022 - May 15, 2013
Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid … August 18, 2021
Potentially inappropriate medications and their effect on falls during … hospital admission. … March 23, 2022
Opioids and falls risk in older adults: a narrative review. … June 16, 2019
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Hospitals
Long-Term
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psnet.ahrq.gov/issue/investigating-long-term-consequences-adverse-medical-events-among-older-adults
March 24, 2019 - September 27, 2023
Cost of inpatient falls and cost-benefit analysis of implementation … July 31, 2008
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries. … Australian hospitals: a mixed methods study. … June 13, 2011
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Hospitals
Risk Managers
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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.