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2081. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
      February 26, 2025 - The organization I am in right now is a 40-hospital system with hundreds of outpatient clinical settings … With falls, for example, we have an aging population. … As we transfer care from hospital-based to ambulatory to home-based, the people who end up in the hospital … population at risk for falls. … health system (i.e., a group of one or more healthcare organizations, such as physician practices, hospitals

2082. Routinely recorded patient safety events in primary care: a literature review. | PSNet
      psnet.ahrq.gov/issue/routinely-recorded-patient-safety-events-primary-care-literature-review
      April 18, 2012 - Routinely recorded patient safety events in primary care: a literature review. … Routinely recorded patient safety events in primary care: a literature review. … From the Same Author(s) A review of patient safety measures based on routinely collected hospital … August 7, 2013 Managing Patients' Medicines after Discharge from Hospital. … May 2, 2012 Primary care–relevant interventions to prevent falling in older adults: a

2083. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/pfp/interimhac2013-ap2.html
      December 01, 2014 - Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to … in the Journal of Patient Safety in September 2014 ( http://journals.lww.com/journalpatientsafety/ … Associated With HACs PfP Hospital-Acquired Condition 2010 Measured Baseline for HACs (rounded … in Deaths in 2013: Based on Measured Reductions of HACs in 2013 vs. 2010, and Baseline Projections Made … Line-Associated Bloodstream Infections 18,000 9,200 8,800 49% $149,600,000 1,628 Falls

2084. Disease management: a mid-decade evolution toward patient safety. | PSNet
      psnet.ahrq.gov/issue/disease-management-mid-decade-evolution-toward-patient-safety
      January 28, 2010 - Related Resources From the Same Author(s) Lack of patient knowledge regarding hospital … May 22, 2019 Hospital Survey on Patient Safety Culture: 2016 User Comparative Database … A comparative study measuring the difference of healthcare workers reactions among those involved in … Trainees in Relation to Their Medical Education—EQUIP Study. … Strategies to improve the patient safety outcome indicator: preventing or reducing falls

2085. Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. | PSNet
      psnet.ahrq.gov/issue/workplace-violence-pervasiveness-perioperative-environment-multiprofessional-survey
      November 11, 2020 - Study Workplace violence pervasiveness in the perioperative environment: a multiprofessional … Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. … most common sources of workplace violence were the patient or a family member, friend, or physician in … Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. … October 6, 2016 View More See More About The Topic Hospitals Operating

2086. Innovations in Promoting Hand Hygiene Compliance | PSNet
      psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
      May 01, 2014 - This hand hygiene metric can be used in an overall hospital-wide or in a specific hospital-unit assessment … To be compared from one hospital to another in particular, or even from one ward to another in the same … Some of the data for US hospitals were recently published in the American Journal of Infection Control … , and it's clear that many hospitals have succeeded in applying system change; for example, making sure … infections in United States hospitals.

2087. Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. | PSNet
      psnet.ahrq.gov/issue/identifying-and-quantifying-medication-errors-evaluation-rapidly-discontinued-medication
      February 03, 2011 - June 22, 2009 Information flow during pediatric trauma care transitions: things falling … a children's hospital. … a children's hospital. … November 6, 2015 Cost-benefit analysis of a medical emergency team in a children's hospital … hospital due to the handwritten prescription process.

2088. In Conversation With… Linda Aiken, PhD, RN | PSNet
      psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
      March 01, 2018 - net hospitals , which have been very difficult to get to change on hospital nurse staffing. … well ( 7 ), and there is an increased risk of adverse events and patient falls.( 8 ) Much of the interest … the hospital. … In many countries, hospital mortality rates are used to assess hospital performance. … December 6, 2018 Effect of changes in hospital nursing resources on improvements in patient

2089. Designing the Built Environment for A Culture and System of Patient Safety – A Conceptual, New Design Process (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-Dickerman_84.pdf
      June 04, 2008 - Introduction Hospitals occupy a unique place in our sensibilities. … the past and that patient safety has been a key point in hospital development. … These provisions have been particularly successful in reducing the number of fire deaths in hospitals … hospitals due to fire. … reducing fire deaths in hospitals?

2090. Discharging Our Responsibility | PSNet
      psnet.ahrq.gov/web-mm/discharging-our-responsibility
      January 16, 2019 - In fact, he had been discharged from the hospital just 3 days prior. … For HF patients discharged in 2002 from US hospitals, Joint Commission and national HF registry data … Hospitals face substantial challenges in providing this important element of HF care. … Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. … Related Resources Patient Safety Innovations Preventing Falls

2091. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851870/psn-pdf
      July 31, 2023 - After nursing school, I worked as a staff nurse in a hospital, then as a director of nursing in a long-term … That is the microsystem of the learning system in Pennsylvania and what is happening within each hospital … We advise hospitals through publication. … event and risk information back to health systems in order to impact hospital processes related to … We were working not on falls or adverse drug reactions, but on the overarching issues that could make

2092. Most Common Cause of Injuries Treated in Emergency Departments
      hcup-us.ahrq.gov/reports/infographics/injurytreated.jsp
      March 01, 2021 - Most Common Cause of Injuries Treated in Emergency Departments … ICD-9-CM Surgery Flags for ICD-9-CM HCUP Supplemental Files NIS-Trend Weights Files NIS Hospital … 1993-2002 Discharge-Level Supplemental Files KID-Trend File Cost-to-Charge Ratio (CCR) Files Hospital … Market Structure (HMS) Files Supplemental Variables for Revisit Analyses American Hospital Association … Picture of AHRQ Logo) 2017 Of 26.5 Million Injury-Related Emergency Related Visits, Falls

2093. Infectious Complications Related to the Catheter Other Than CAUTI | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/infectious-complications-slides.html
      December 01, 2017 - hospitals Mortality up to 50%, with limited antimicrobials available Slide 10 CRE: What is … (MMWR 2013; 62 (9):165-70) Estimate of the proportion of CRE in US hospitals: At least one CRE … infection (1st 6 months 2012): 3.9% short acute care hospitals and 17.8% in long term acute care hospitals … MDROs and CAUTI: NHSN 2009-10 (Sievert, Infect Control Hosp Epidemiol 2013; 34: 1-14) 2,039 hospitals … Workload issues leading to work-arounds Weighing risk of catheters v. other issues (i.e. falls)

2094. Handoff strategies in settings with high consequences for failure: lessons for health care operations. | PSNet
      psnet.ahrq.gov/issue/handoff-strategies-settings-high-consequences-failure-lessons-health-care-operations
      March 14, 2018 - Associations between perceived crisis mode work climate and poor information exchange within hospitals … March 11, 2020 Information flow during pediatric trauma care transitions: things falling … June 18, 2019 Improving patient safety in public hospitals: developing standard measures … April 4, 2018 Medication errors in injured patients. … 2017 Information handoff and outcomes of critically ill patients transferred between hospitals

2095. Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites. | PSNet
      psnet.ahrq.gov/issue/diagnostic-errors-interpretation-pediatric-musculoskeletal-radiographs-common-injury-sites
      August 02, 2015 - Study Diagnostic errors in interpretation of pediatric musculoskeletal radiographs … were relatively rare, occurring in 2.7% of cases. … January 3, 2017 Diagnostic delays in paediatric stroke. … December 14, 2016 Diagnostic errors in pediatric radiology. … December 14, 2016 View More See More About The Topic Children's Hospitals

2096. Teaching quality improvement. | PSNet
      psnet.ahrq.gov/issue/teaching-quality-improvement
      July 19, 2023 - hospital practice: factors associated with turnover, outcomes, and patient safety. … 2009 Conducting an efficient proactive risk assessment prior to CPOE implementation in … February 1, 2012 Estimation of breast cancer overdiagnosis in a U.S. breast screening … January 12, 2022 CT for suspected appendicitis in children: an analysis of diagnostic … May 4, 2015 Fall prevention in hospitals: an integrative review.

2097. Sustainability-Tool (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
      May 01, 2017 - Sustainability Sustainability Tool Background: This tool can be used to identify sustainability issues in … Are information systems in place to support the effort going forward? … Are there opportunities for varied geographic participation (e.g., among units within a hospital; among … hospitals within a consortium; participation in regional vs. national initiative)? … Are varied roles for participation in the project provided?

2098. Identifying unintended consequences of quality indicators: a qualitative study. | PSNet
      psnet.ahrq.gov/issue/identifying-unintended-consequences-quality-indicators-qualitative-study
      March 04, 2020 - multistate hospital network--13 academic medical centers, April-June 2020. … April 11, 2011 Involving patients and carers in patient safety in primary care: a qualitative … September 18, 2024 Families as partners in hospital error and adverse event surveillance … May 16, 2012 Managing Patients' Medicines after Discharge from Hospital. … March 10, 2011 Primary care–relevant interventions to prevent falling in older adults

2099. Work system barriers and facilitators of a team health information technology. | PSNet
      psnet.ahrq.gov/issue/work-system-barriers-and-facilitators-team-health-information-technology
      March 11, 2020 - March 11, 2020 Information flow during pediatric trauma care transitions: things falling … functions and outcomes in two handoff processes. … February 19, 2020 Using an inpatient portal to engage families in pediatric hospital … a multistate hospital network--13 academic medical centers, April-June 2020. … hospital after electronic health record implementation: sociotechnical and human factors engineering

2100. The Medication Metronome Project | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/medication-metronome-project
      January 01, 2023 - Report ( PDF , 850.24 KB) Disclaimer Disclaimer The findings and conclusions in … No statement in this report should be construed as an official position of AHRQ or of the U.S. … Organization Massachusetts General Hospital Location Boston Massachusetts … However, national and local data indicate that the United States health care system is falling significantly … (Prepared by Massachusetts General Hospital under Grant No. R18 HS018648).