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Showing results for "falls in hospitals".
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3341. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
      November 01, 2006 - public-private collaboration established to encourage hospitals to voluntarily collect and report hospital … Hospital Quality Alliance (HQA) Began in 2003 with 10 quality measures spread across 3 clinical conditions … Wisconsin: A report on the impact of the Quality Counts program in Wisconsin found that hospitals involved … to improve care Hospitals may decide to hire additional clinical personnel to improve performance from … Care in U.S. hospitals--the Hospital Quality Alliance program.

3342. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49630/psn-pdf
      July 01, 2011 - Case & Commentary—Part 1: A frail 80-year-old man with a past medical history of dementia, falls, and … atrial fibrillation presented to the hospital with confusion and weakness. … the hospital. … the hospital for two days and was being prescribed medications known to interact with warfarin. … In summary, the best practices for the management of warfarin at hospital discharge should focus on the

3343. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) | PSNet
      psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
      April 01, 2005 - In the next few months, you'll see other interviews and essays covering topics such as how hospitals … research on preventing falls in nursing homes, or a physician interested in strategies to prevent wrong-site … In a couple of intensive care units in a single hospital, it is pretty difficult to measure a difference … In our study it didn't cost anything more, because at Brigham & Women's Hospital, the internal medicine … CL: I think that the hospital has been rather bold in stepping up and saying that this is something

3344. In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 | PSNet
      psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
      February 28, 2024 - The program was initially implemented mainly in hospitals, and later it did spread to other healthcare … hospitals and other care settings, sometimes in response to a patient harm, and other times because … It is easy to talk about how communication should happen, for example, in a surgery unit in a hospital … Aside from training large medical centers and hospitals, a big emphasis will be put on training in various … seen frequently with virtual teams where a diagnosis isn’t communicated quickly enough, or something falls

3345. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49531/psn-pdf
      March 01, 2007 - The vials, in the three sizes used to make the admixtures, are all contained in the same Pyxis drawer … The nurse's failure to confirm the medication's identity prior to administration falls into the category … A study of hospital nursing units found that higher reporting rates were correlated with unit members … In: Spath PL. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. … Checking for biases in incident reporting. In: Phimister JR, Bier VM, Kunreuther HC.

3346. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49783/psn-pdf
      February 01, 2017 - The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting … She did well with no new complaints or complications and was discharged from the hospital the following … The patient was readmitted to the same hospital medicine team that had cared for her before. … The hospital medicine service routinely reviewed all deaths on their service. … Wiprud R. 30 standardized hospital admission orders. Fam Pract Manag. 2001;8:49-51.

3347. Critical Echocardiogram Result Lost to Follow-up | PSNet
      psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
      July 31, 2023 - After the patient was readmitted with endocarditis, he had a complicated hospital course resulting in … in this case involved the transition from hospital to skilled nursing facility. … Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. … The incidence and nature of in-hospital adverse events: a systematic review. … Adverse Events in Hospitals: Case Study of Incidence Among Medicare Beneficiaries in Two Selected Counties

3348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33879/psn-pdf
      May 01, 2019 - In Conversation With… Jane Brice, MD, MPH May 1, 2019 In Conversation With… Jane Brice, MD, MPH. … only have 12 minutes between the time you pick them up and get to the hospital to make a difference … take the patient to the hospital, and never ask the question, we'll never know. … breathing" and they say, "I have no idea," then you should just take care of the patient and go to the hospital … the hospital so that there is a two-way dataflow.

3349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - The patient was then admitted to the hospital for cranioplasty. … the hospital to postacute care. … In the course of his recovery he bounced between multiple acute care hospitals and postacute care facilities … Hospitals in the United States are reimbursed under a system known as "prospective payment," in which … any cost savings.(4) Another example is bundled payments, in which hospitals and postacute care facilities

3350. Post-Acute Transitional Services: Safety in Home-Based Care Programs | PSNet
      psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
      April 24, 2024 - Home-based care programs can accept patients discharged from hospitals either in their home or an assisted … functionally frail patients who are also at higher risk for patient safety events such as medication errors, falls … or mortality. 24 Patients discharged from hospitals to HHA care have accounted for 25% of hospital … Hospital at home versus in-patient hospital care.  … Hospital-at-Home interventions vs in-hospital stay for patients with chronic disease who present to the

3351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49520/psn-pdf
      September 01, 2006 - her advance directive, which accompanied the patient to the hospital). … Fortunately, the error led to no inappropriate resuscitative measures, but the event did generate a hospital … in the hospital. … identifying surgical patients who have a DNR order may be a challenge if the patient is new to the hospital … Finally, hospitals should consider back-up systems for essential but difficult parts of a critical pathway

3352. Informed or Misled? | PSNet
      psnet.ahrq.gov/web-mm/informed-or-misled
      April 24, 2018 - The Case A 50-year-old man arrived at the hospital for an elective total knee replacement. … The patient reportedly signed an anesthesia permit required by this hospital that stated that any change … This is particularly relevant if hospital policy requires that consent be obtained in advance of the … White, FRCA, BSc, MA Consultant Anaesthetist, Brighton and Sussex University Hospitals NHS Trust, UK … hospital error and adverse event surveillance.

3353. Mark My Limb | PSNet
      psnet.ahrq.gov/web-mm/mark-my-limb
      February 10, 2015 - recovery room, multiple, seemingly simple processes—involving doctors, nurses, technicians, and other hospital … in these schools. … the Same Author(s) Performance-based payment incentives increase burden and blame for hospital … Comparison of traditional trigger tool to data warehouse based screening for identifying hospital … Post-discharge adverse events among African American and Caucasian patients of an urban community hospital

3354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72589/psn-pdf
      December 23, 2020 - new diagnoses and 42,000 deaths in the US in 2017.1 Early detection and appropriate treatment have … study by The Doctor’s Company and CRICO, the captive malpractice insurer of the Harvard-affiliated hospitals … the finding before recommending management limited to routine mammography screening.”12 BI-RADS 3 falls … Schiff, MD Brigham and Women’s Hospital Harvard Medical School Ted James, MD Chief, Breast Surgical … (PRIDE) Learning Network, a collaborative project convened by the Brigham and Women’s Hospital Center

3355. The Hazards of Distraction: Ticking All the EHR Boxes | PSNet
      psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
      April 09, 2014 - The patient was alert and oriented when she arrived in the ED, but she did report falling and hitting … The patient was readmitted to the same hospital medicine team that had cared for her before. … The hospital medicine service routinely reviewed all deaths on their service. … Wiprud R. 30 standardized hospital admission orders. Fam Pract Manag. 2001;8:49-51. … the Code February 1, 2006 View More See More About The Topic Hospitals

3356. Unexpected Drawbacks of Electronic Order Sets | PSNet
      psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
      December 01, 2017 - Before the hospital transitioned to computerized provider order entry (CPOE), orders for common electrolytes … When the hospital recently switched from paper orders to CPOE, all order sets were imported into the … the Hospital With Advanced Dementia December 1, 2017 Transitions from one … Leads to Sepsis October 1, 2016 WebM&M Cases Falling … Electronic Err October 1, 2004 View More See More About The Topic Hospitals

3357. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49827/psn-pdf
      April 01, 2018 - walking-patient-missing-drain The Case A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital … upright activity and walking while in the ICU. … Although rare, adverse events during early mobilization have included falls, line dislodgement, ventilator … Criteria for participation in early mobilization in the intensive care unit should be established to … therapy in the ICU.

3358. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836941/psn-pdf
      April 27, 2022 - Home-based care programs can accept patients discharged from hospitals either in their home or an assisted … functionally frail patients who are also at higher risk for patient safety events such as medication errors, falls … or mortality.24 Patients discharged from hospitals to HHA care have accounted for 25% of hospital readmissions … Hospital at home versus in-patient hospital care.?Cochrane Database Syst Rev. 2005;(3):CD000356. … Hospital-at-Home interventions vs in-hospital stay for patients with chronic disease who present to

3359. In Conversation With… Rebecca Lawton, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
      March 24, 2025 - At the time, British Rail had a problem in that about one in a thousand shunters were dying every year … RW : In terms of what you eventually ended up applying in patient safety, what were the general lessons … RW : In some ways, you've demonstrated that making change in complex organizations is hard. … Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, … , MPH September 1, 2007 View More See More About The Topic Hospitals

3360. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
      July 01, 2006 - After developing hypoxemia, on hospital day 2 she was placed on 2L oxygen by nasal cannula. … On hospital day 3, her hypoxemia worsened, as did her mental status. A head CT was ordered. … peer-reviewed articles cover transport of non-ICU patients Recognizing risk of intrahospital transport, many hospitals … Hospital did have system for assessing and communicating a patient’s clinical stability, but assessment … Are they in main hospital, adjacent buildings, across the street?