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psnet.ahrq.gov/issue/commentary-sentinel-serious-events-reported-district-health-boards-200607
March 05, 2008 - Zealand hospitals. … hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital … January 1, 2012
Your Safety in our Hands in Hospital. … November 8, 2023
Home Health Agencies Failed To Report Over Half of Falls With Major … December 4, 2019
Adverse Events in Hospitals: Public Disclosure of Information About
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psnet.ahrq.gov/issue/health-care-leader-action-guide-reduce-avoidable-readmissions
March 14, 2018 - This guide introduces strategies for hospital managers to prevent avoidable readmissions . … Hospitals, 2010 Versus 2014. … October 23, 2019
Origin of Adverse Drug Events in US Hospitals, 2011. … October 9, 2013
Hand Hygiene Project: Best Practices from Hospitals Participating in … 31, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - In fact, Dall et al., 2009, found that there
were economic benefits to hospitals with better staffing … One classic study showed lower
inpatient mortality rates for a variety of surgical patients in hospitals … Beginning in 1983, the program sought to identify hospitals which had lower turnover
rates and above … Effect of changes in hospital nursing resources on
improvements in patient safety and quality of care … Correlates and predictors of missed nursing care in
hospitals.
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psnet.ahrq.gov/issue/staying-safe-while-getting-well
February 05, 2014 - Patients can help minimize the potential for adverse events while in the hospital. … March 20, 2024
Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital … complications: a medical record review across nine Swiss hospitals. … January 10, 2024
Patient Safety Innovations
Preventing Falls … But are hospitals getting any safer?
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psnet.ahrq.gov/issue/cracking-code-quality-interrelationships-culture-nurse-demographics-advocacy-and-patient
December 01, 2011 - March 11, 2020
Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital … March 18, 2020
View More
Related Resources
Patient falls in the … June 16, 2021
Fall prevention implementation strategies in use at 60 United States hospitals … U.S. acute care hospital units: a cross-sectional study. … medical and surgical wards of selected hospitals in Kuwait.
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psnet.ahrq.gov/issue/supporting-second-victims
February 15, 2023 - Involvement in patient harm can result in serious psychological consequences for health care workers … October 10, 2018
Preventing newborn falls and drops. … December 18, 2017
Do hospitals support second victims? … Collective insights from patient safety leaders in Maryland. … September 19, 2016
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See More About The Topic
Hospitals
Health
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psnet.ahrq.gov/issue/how-well-do-incident-reporting-systems-work-inpatient-psychiatric-units
September 05, 2018 - hospitals. … Conducted in inpatient psychiatric units at Veterans Affairs hospitals, the study found that only a … November 18, 2016
Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals … September 27, 2017
Inpatient suicide and suicide attempts in Veterans Affairs hospitals … September 19, 2016
Using root cause analysis to reduce falls with injury in the psychiatric
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psnet.ahrq.gov/issue/medication-safety-dashboard
April 15, 2020 - Same Author(s)
Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals … The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020 … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls … 2019
SOPS Health Information Technology Patient Safety Supplemental Item Set for the Hospital … June 11, 2014
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See More About The Topic
Hospitals
Ambulatory
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - compliance—a key factor associated with the spread of HAI.( 10 ) Bronson Methodist Hospital in Kalamazoo … Because most studies in this area have involved multifaceted-interventions to reduce falls ( 17-19 ), … Systematic review of studies on compliance with hand hygiene guidelines in hospital care. … The impact of healthcare environmental design on patient falls. … Health Care
August 1, 2009
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See More About The Topic
Hospitals
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psnet.ahrq.gov/issue/incorporating-health-information-technology-workflow-redesign-request-information-summary
September 29, 2017 - April 23, 2014
Patient Safety in Ambulatory Settings. … May 2, 2018
Hospital Survey on Patient Safety Culture: 2018 User Database Report. … April 22, 2018
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care … March 27, 2019
Transforming Hospitals: Designing for Safety and Quality. … August 28, 2013
Characteristics of Weekday and Weekend Hospital Admissions, 2007.
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psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
February 11, 2015 - Hospitals. … February 11, 2015
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced … May 25, 2022
Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events … October 29, 2008
Home Health Agencies Failed To Report Over Half of Falls With Major … November 8, 2023
Patient Safety Organizations: Hospital Participation, Value, and Challenges
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psnet.ahrq.gov/issue/high-reliability-truly-achieving-healthcare-quality-and-safety
March 18, 2019 - Prospective study of the multisite spread of a medication safety intervention: factors common to hospitals … May 1, 2013
Staff attitudes about event reporting and patient safety culture in hospital … hospitals: responding to The Joint Commission leadership standard—part 1 and part 2. … May 19, 2013
Minnesota Hospital Association Statewide Project: SAFE from FALLS. … July 21, 2010
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See More About The Topic
Hospitals
Health Care
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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - Sarah Mossburg: Some hospitals have reported zero harm for some types of adverse events, such as
hospital-acquired … That is not the case for falls. Hospitals do find out about nearly every fall. … For example, because it’s required, hospitals do a reasonably good job of
detecting hospital acquired … Sarah Mossburg: One of the things you have noted is that variation in how well hospitals prevent falls … harms
continue to occur at higher rates in some hospitals.
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psnet.ahrq.gov/issue/rural-nurses-safeguarding-work-reembodying-patient-safety
December 09, 2009 - Rural hospitals face similar patient safety issues as larger urban facilities, but may need different … This qualitative study explores the various patient safety roles assumed by nurses in rural hospitals … April 21, 2021
Nursing and patient safety in the operating room. … Related Resources
Patient Safety Innovations
Preventing Falls … July 28, 2010
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See More About The Topic
General Hospitals
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psnet.ahrq.gov/primer/never-events
June 15, 2024 - For example, a 2006 study estimated that a typical hospital might experience a case of wrong-site surgery … The Joint Commission has recommended that hospitals report " sentinel events " since 1995. … September 4, 2024
Patient falls in the operating room: why is this still a problem in 2024? … July 12, 2023
How can never event data be used to reflect or improve hospital safety … View More
See More About The Topic
Sentinel Event
Never Events
Hospitals
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psnet.ahrq.gov/node/50775/psn-pdf
January 01, 2021 - content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-
handovers-and
This study reviewed incident reports involving older adult patient transitions in … interunit/department/team transfers and the majority (69%) of incidents were related to pressure injuries,
falls … content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
https://psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
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psnet.ahrq.gov/issue/association-patient-safety-climate-and-nurse-related-organizational-factors-selected-patient
January 22, 2014 - Hospital units: an exploratory study. … April 20, 2022
Nurse staffing and education and hospital mortality in nine European countries … January 4, 2015
Interventions for preventing falls in acute- and chronic-care hospitals … May 12, 2021
Do safety briefings improve patient safety in the acute hospital setting … October 21, 2010
Expanding what we know about off-peak mortality in hospitals.
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psnet.ahrq.gov/issue/scottish-patient-safety-alliance
July 29, 2015 - September 28, 2023
Hospital Compare. … April 24, 2013
Minnesota Hospital Association Statewide Project: SAFE from FALLS. … Hospital Care. … October 12, 2011
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries … September 20, 2011
View More
See More About The Topic
Hospitals
Health
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psnet.ahrq.gov/issue/procedures-should-promote-patient-safety
March 01, 2007 - Hospital peer review. 2006;31(8):113-6. … This article discusses the importance of developing practical procedures in hospital care and how to … Related Resources
Patient Safety Innovations
Preventing Falls … hospital safety: a systematic review and meta-analysis of hospital adverse events. … best practices in US hospitals.
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psnet.ahrq.gov/issue/medication-errors-older-people-mental-health-problems-review
April 27, 2022 - delays to identification of serious injury after falls in hospital inpatients. … human factors methods to ensure appropriate infant identification and abduction prevention within the hospital … mental health hospitals: a systematic review. … Australian hospitals: a mixed methods study. … September 13, 2017
How can we keep patients with dementia safe in our acute hospitals