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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
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Hospitals
Nurse
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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/medical-mistakes-no-longer-billable-bold-steps-taken-state-reduce-hospital-errors
August 06, 2008 - Massachusetts government and state insurers have outlined policies whereby they will not reimburse hospitals … August 6, 2008
Most surgery in wrong spot done on spine: 11 such cases found in state … June 10, 2015
Man falls off surgical table; St. Joseph's Hospital sued. … Safety
Health Plan Patient Safety Initiatives
July 10, 2024
Hospitals … Donaldson, MD, MSc
May 1, 2007
Hospitals save money, but safety is questioned
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psnet.ahrq.gov/issue/using-workforce-practices-drive-quality-improvement-guide-hospitals
March 22, 2017 - March 22, 2017
Hand Hygiene Project: Best Practices from Hospitals Participating in the … May 6, 2015
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final … May 24, 2015
Preventing Patient Falls: A Systematic Approach From the Joint Commission … October 27, 2016
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Related Resources
Preventing violence in … September 24, 2016
Interdisciplinary teamwork in hospitals: a review and practical recommendations
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psnet.ahrq.gov/issue/patient-safety-tools-improving-safety-point-care-0
September 08, 2021 - Facebook
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Linkedin
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November 14, 2011
Produced in … conjunction with its Partnerships in Implementing Patient Safety (PIPS) grant program, AHRQ has released … 17 freely available toolkits to help hospitals and health care providers reduce medical errors. … September 8, 2021
Toolkit To Improve Antibiotic Use in Acute Care Hospitals
December … April 6, 2016
Preventing Falls With Injury.
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psnet.ahrq.gov/issue/clinicians-perceptions-opioid-error-contributing-factors-inpatient-palliative-care-services
June 01, 2016 - care after leaving hospital: what works for whom and why? … The impact of safety culture, quality of care, missed care and nurse staffing on patient falls … acute-care hospitals. … 27, 2024
Patient Safety Innovations
Preventing Falls … April 4, 2011
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Hospitals
Health Care
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - infections, falls, pressure ulcers, and inpatient suicide. … An NPSG in the hospital setting includes preventing surgical errors by ensuring that the right surgical … A nursing care center goal includes preventing falls in patients and nursing home residents by identifying … individuals at risk for falls, such as those taking medications that could result in weakness, dizziness … The goal additionally includes taking steps to prevent falls in these high-risk individuals.
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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/less-more-project-reduce-number-pims-potentially-inappropriate-medications-elderly-care-ward
September 27, 2017 - environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals … May 25, 2016
Development of a checklist of safe discharge practices for hospital patients … June 1, 2012
Effect of medication reconciliation at hospital admission on medication … June 1, 2012
Utilizing quality improvement methods to prevent falls and injury from falls … Hold the tPA
April 1, 2005
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Hospitals
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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/implementation-evaluation-and-recommendations-extension-ahrq-common-formats-capture-patient
June 13, 2018 - July 29, 2020
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … July 18, 2016
Cost of inpatient falls and cost-benefit analysis of implementation of … July 25, 2018
Families as partners in hospital error and adverse event surveillance. … hospital. … April 6, 2011
What pilots can teach hospitals about patient safety.
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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/how-safety-compromised-when-hospital-equipment-poor-fit-patients-who-are-obese
October 07, 2020 - Study
How safety is compromised when hospital equipment is a poor fit for patients … How safety is compromised when hospital equipment is a poor fit for patients who are obese. … ., falls, pressure injuries, skin tears, abrasions). … How safety is compromised when hospital equipment is a poor fit for patients who are obese. … errors reported by 101 hospitals from 2011 to 2020.
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psnet.ahrq.gov/issue/health-care-leaders-action-guide-hospital-strategies-reducing-preventable-mortality
May 06, 2015 - October 19, 2016
Hand Hygiene Project: Best Practices from Hospitals Participating in … May 24, 2015
Preventing Patient Falls: A Systematic Approach From the Joint Commission … November 21, 2016
Improving Diagnosis in Medicine Change Package. … November 14, 2011
IBEAS: A Pioneer Study on Patient Safety in Latin America: Towards … Safer Hospital Care.
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psnet.ahrq.gov/issue/am-i-safe-here-improving-patients-perceptions-safety-hospitals
June 25, 2010 - Improving patients' perceptions of safety in hospitals. … : improving patients' perceptions of safety in hospitals. J Nurs Care Qual. 2006;21(1):30-40. … : improving patients' perceptions of safety in hospitals. J Nurs Care Qual. 2006;21(1):30-40. … June 24, 2010
The safety culture in a children's hospital. … January 10, 2011
Do falls and other safety issues occur more often during handovers when
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - Falls are a classic example of something that there's almost no point in reporting. … Falls are a common enough problem at every hospital that you
should stop doing incident reports. … So if there's one person in the quality department,
like at many hospitals, then even without a big … When you hear of a
hospital and they tell you their incident reports have gone up 30% in the last year … Other hospitals in North America would just have a hotline, and other
hospitals have made a paper-based
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psnet.ahrq.gov/issue/engaging-patients-and-family-members-patient-safety-experience-new-york-city-health-and
October 19, 2022 - New York City Health and Hospitals Corporation. … Hospitals Corporation. … The article outlines initiatives undertaken by the New York City Health and Hospitals Corporation to … Hospitals Corporation. … October 21, 2010
National Center for Patient Safety Falls Toolkit 2004.
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psnet.ahrq.gov/issue/comparing-process-and-outcome-oriented-approaches-voluntary-incident-reporting-two-hospitals
June 15, 2011 - Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. … Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. … October 22, 2008
Implementing computerized provider order entry in acute care hospitals … May 24, 2015
Variation in the rates of adverse events between hospitals and hospital … November 25, 2009
Falls in English and Welsh hospitals: a national observational study
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psnet.ahrq.gov/node/865296/psn-pdf
March 27, 2024 - infections, falls, pressure
ulcers, and inpatient suicide. … An NPSG in the hospital
setting includes preventing surgical errors by ensuring that the right surgical … A nursing care center goal includes preventing falls in patients and nursing home residents by
identifying … individuals at risk for falls, such as those taking medications that could result in weakness,
dizziness … The goal additionally includes taking steps to prevent falls in these high-risk
individuals.
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psnet.ahrq.gov/issue/adverse-event-reporting-practices-us-hospitals-results-national-survey
December 30, 2014 - Results indicate that, by these criteria, the majority of hospitals do not have effective systems in … September 20, 2011
Families as partners in hospital error and adverse event surveillance … in hospitals. … May 17, 2012
An inpatient fall prevention initiative in a tertiary care hospital. … December 14, 2009
Falls in English and Welsh hospitals: a national observational study