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psnet.ahrq.gov/node/865816/psn-pdf
May 08, 2024 - managers, videos, and a safety handbook to encourage home care recipients to create safer
conditions in … common improvement
following the nurse manager visit was improved access into the home and a reduction in … challenge-risk-prevention-home-healthcare-interview-study-nurses-municipal-care
https://psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half-falls-major-injury-and-hospitalization-among
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psnet.ahrq.gov/web-mm/empty-bag
June 01, 2018 - Injuries are caused by a lack of differentiation between the use of infusion devices in hospitals and … Products designed for the hospital environment are being used in home environments (and vice versa). … Evolution and Progress
May 1, 2007
WebM&M Cases
Falling … to 20 hospitals in England during implementation of the 7-day services national health policy. … February 14, 2024
Patient Safety Innovations
Preventing Falls
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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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Hospitals
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psnet.ahrq.gov/issue/demonstrating-value-postgraduate-fellowships-physicians-quality-improvement-and-patient
November 04, 2015 - Study
Demonstrating the value of postgraduate fellowships for physicians in quality … Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient … all being involved in QIPS administration, research or education upon graduation. … Bridging the gap: a framework and strategies for integrating the quality and safety mission of teaching hospitals … September 11, 2019
Associations between in-hospital mortality, health care utilization
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www.ahrq.gov/evidencenow/projects/urinary/optima-interview.html
November 01, 2024 - - from academic hospitals to rural clinics. … In doing so, we seek to address the significant deficits in quality UI care. … We are also interested in reducing disparities in care, so we seek to examine different intersections … Recognizing that UI is highly stigmatized and the burden of initiating a UI conversation often falls … offices in urban areas, we were able to measure how often “interruptive” alerts (in the form of a pop-up
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psnet.ahrq.gov/issue/medical-mystery-alcoholism-didnt-cause-mans-diabetes-and-cirrhosis
July 06, 2011 - This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute … September 25, 2019
Insulin pumps have most reported problems in FDA database. … November 28, 2016
Patients as Partners: How to Involve Patients and Families in Their … September 8, 2010
How to avoid falling victim to a hospital mistake. … November 25, 2009
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Hospitals
Patients
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psnet.ahrq.gov/issue/partially-structured-postoperative-handoff-protocol-improves-communication-2-mixed-surgical
November 19, 2018 - Study
A partially structured postoperative handoff protocol improves communication in … between the operating room and the intensive care unit (ICU) across two surgical ICUs at two hospitals … February 15, 2023
Changes in hospital-acquired conditions and mortality associated with … the hospital-acquired condition reduction program. … May 14, 2014
In search of common ground in handoff documentation in an intensive care
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psnet.ahrq.gov/issue/economics-health-care-quality-and-medical-errors
August 19, 2020 - Discussing the financial impact of medical errors, this commentary describes four hospitals' efforts … January 12, 2022
Postdischarge adverse events for 1-day hospital admissions in older … September 21, 2011
Steering patients to safer hospitals? … The effect of a tiered hospital network on hospital admissions. … October 27, 2010
Hospitals find confession good for the bottom line.
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psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-system-innovation-concord-hospital
October 19, 2022 - System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672. … System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672. … May 31, 2023
Mortality among patients in VA hospitals in the first 2 years following … hospital. … Epilogue
April 1, 2009
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Hospitals
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www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-health-equity.html
May 01, 2024 - Grant Summaries
P1: Does A New Care Model Improve Care for Patients with Acute Kidney Injury After Hospital … ; Independent Hospital Examines whether the Patient Protection and Affordable Care Act (ACA)-related … Medical Center; Independent Hospital Evaluates the impact of different delivery models on health outcomes … The most common unintentional injury was drug overdose, accidental falls, and motor vehicle accidents … However, the number of healthcare workers continues to decrease in hospitals and nursing and residential
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digital.ahrq.gov/ahrq-funded-projects/evaluation-scaled-scaling-acceptable-cds-approach-implementation-interoperable-cds-venous
July 31, 2025 - SMART/FHIR
Patient-Generated Health Data
Care Setting
Academic Medical Center
Hospital … to scale and evaluate the implementation of a CDS tool for venous thromboembolism (VTE) prophylaxis in … In parallel with the effectiveness-implementation trial, researchers will also conduct a mixed-methods … goal was, can we develop this decision support system as an app and make it as easy to scale to other hospitals … Related Stories A Clinical Decision Support Tool for Preventing Falls
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
March 09, 2005 - We did so because we believed that falls and delirium
pose the largest threats to patient safety in … reducing the risk of falling includes review and adjustment of
medications.28 Delirium is highly prevalent … The Falls Medication Monitoring Care Plan
Advances in Patient Safety: Vol. 4
410
Figure 3. … Falls and
fall prevention in the nursing home. Clin Geriatr Med
1996 Nov;12(4):881–902.
25. … A longitudinal study
of falls in an elderly population: I. Incidence and
morbidity.
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digital.ahrq.gov/sites/default/files/docs/citation/u18hs026154-crane-final-report-2023.pdf
January 01, 2023 - about falls in the prior year as well as falls requiring a visit
to the Emergency Department, the Narcan … other key
groups likely to benefit from a falls assessment in the PROs. … Illicit substance use and falls among people with HIV in care in
the United States. 25th International … Detecting panic disorder in medical and psychosomatic outpatients:
comparative validation of the Hospital … Illicit substance use and falls among people with HIV in
care in the United States. 25th International
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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/screening-adverse-drug-events-randomized-trial-automated-calls-coupled-phone-based-pharmacist
June 05, 2018 - In this cluster-randomized trial, researchers examined the impact of an automated phone call with the … May 1, 2019
Analysis of variations in the display of drug names in computerized prescriber-order-entry … 21, 2018
Evaluation of medication-related clinical decision support alert overrides in … May 10, 2017
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital
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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
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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/audit-missed-or-delayed-antimicrobial-drugs
August 01, 2012 - hospital settings in the United Kingdom. … Hospitals Were Reported to State Adverse Event Reporting Systems. … August 1, 2012
Adverse Events in Hospitals: Public Disclosure of Information About Events … delays to identification of serious injury after falls in hospital inpatients. … May 13, 2009
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Hospitals
Physicians
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psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards
February 13, 2013 - Minnesota Hospital Association. … Minnesota Hospital Association. … A COVID-19 Resource for Hospital and Health System Leaders. … July 23, 2024
Patient Safety Innovations
Preventing Falls … September 9, 2010
Fixing America's hospitals.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
September 01, 2011 - She immediately complained of hip pain and was transferred to an acute care hospital. … Because of concerns for an acute infection, she was transferred to an acute care hospital. … *
*
Case: Safety of Long-Term Care (4)
At the hospital, a full examination revealed a very deep … focused on pressure ulcers, adverse drug events (ADEs), and falls
Data regarding incidence of adverse … Comparing the safety culture of nursing homes and hospitals. J Appl Gerontol. 2011;30:22-43.