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2261. Table 8B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8b.html
      February 01, 2023 -   Min 1,663 s s s s   Max 7,916 20,000 16,970 11,285 s Injurious Falls … 1,625 918   Max 11,025 10,192 7,947 11,816 13,629 9,756 9,500 Injurious Falls … All outcome indicators expressed as potentially avoidable hospital stays per 100,000 persons in the HCBS … Eligibility for Medicare defined as inclusion in Medicare Denominator File. … Medicaid only = part of Medicaid HCBS population but not enrolled in Medicare.

2262. Table 8F: HCBS Population Ages 18-64 Without Intellectual/Developmental Disabilities or Serious Mental Illness | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8f.html
      February 01, 2023 -   Min 1,710 s s s s   Max 19,029 26,952 26,016 40,816 s Injurious Falls … s s 2,151 s   Max 31,755 11,573 19,518 s s 19,248 23,318 Injurious Falls … All outcome indicators expressed as potentially avoidable hospital stays per 100,000 persons in the HCBS … Eligibility for Medicare defined as inclusion in Medicare Denominator File. … Medicaid only = part of Medicaid HCBS population but not enrolled in Medicare.

2263. Table 8C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8c.html
      February 01, 2023 -   Min s s s s s   Max 6,520 26,790 16,901 21,429 s Injurious Falls … s 785 s   Max 13,444 6,692 10,428 7,489 9,506 12,207 6,952 Injurious Falls … All outcome indicators expressed as potentially avoidable hospital stays per 100,000 persons in the HCBS … Eligibility for Medicare defined as inclusion in Medicare Denominator File. … Medicaid only = part of Medicaid HCBS population but not enrolled in Medicare.

2264. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866247/psn-pdf
      July 10, 2024 - ) has been used to categorize patient safety reports and reduce the burden of manual review within hospitals … or hospital networks. … Most incidents were medication-related, followed by patient falls, and incidents related to venous thromboembolism

2265. Quality Improvement Strategies | Agency for Healthcare Research and Quality
      www.ahrq.gov/pqmp/implementation-qi/toolkit/h2h/qi-strategies.html
      July 01, 2021 - content…” Before the start of the Collaborative, interviews were conducted with the high performing hospitals … Participating teams conducted a gap analysis comparing their practices with those outlined in the Key … A description of the team’s approach based on this tool is available in the How to Use the Change Package … Built-in error proofing. … Each of these strategies, lessons learned, and vignettes from participating hospitals can be adapted

2266. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836959/psn-pdf
      April 20, 2022 - safety-elderly-fallers-identifying-associated-risk-factors-30-day-unplanned- readmissions Older adults are at high risk for 30-day unplanned hospital … readmissions-and-adverse-events-after-discharge https://psnet.ahrq.gov/issue/readmissions-observation-and-hospital-readmissions-reduction-program

2267. Making Healthcare Safer Practices: 14. Delirium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/delirium-1.pdf
      March 01, 2020 - two tertiary hospitals. … and in a wide variety of settings other than hospitals and the ICU. … two university hospitals in Seoul, Korea. … Two chart reviews were performed on patient falls as identified in the hospital safety reporting … The fall rates in 2011 and 2012 were 3.01 and 2.82 falls per 1,000 patient days and in 2013 decreased

2268. Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. | PSNet
      psnet.ahrq.gov/issue/clinical-uncertainty-primary-care-challenge-collaborative-engagement
      December 23, 2008 - Book/Report Clinical Uncertainty in Primary Care: The Challenge of Collaborative … Citation Text: Clinical Uncertainty In Primary Care. … fall prevention in a nursing home. … August 8, 2014 Engaging Patients in Improving Ambulatory Care. … February 28, 2011 Deficits in communication and information transfer between hospital-based

2269. Taking risky business out of the MRI suite. | PSNet
      psnet.ahrq.gov/issue/taking-risky-business-out-mri-suite
      September 12, 2016 - Materials management in health care. 2006;15(1):18-23. … Materials management in health care . 2006; 15 (1) :18-23 . … Materials management in health care. 2006;15(1):18-23. … January 26, 2022 Improving handoffs in the emergency department. … common cause analysis of safety events at a pediatric hospital.

2270. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. | PSNet
      psnet.ahrq.gov/issue/towards-framework-select-techniques-error-prediction-supporting-novice-users-healthcare
      March 28, 2011 - Towards a framework to select techniques for error prediction: supporting novice users in … Towards a framework to select techniques for error prediction: supporting novice users in the healthcare … Towards a framework to select techniques for error prediction: supporting novice users in the healthcare … September 27, 2023 Medication errors in anesthesiology: is it time to train by example … July 19, 2019 Errors and discrepancies in the administration of intravenous infusions

2271. Physician Quality Officer: a new model for engaging physicians in quality improvement. | PSNet
      psnet.ahrq.gov/issue/physician-quality-officer-new-model-engaging-physicians-quality-improvement
      May 03, 2017 - Commentary Physician Quality Officer: a new model for engaging physicians in quality … Physician quality officer: a new model for engaging physicians in quality improvement. … Physician quality officer: a new model for engaging physicians in quality improvement. … March 14, 2022 Medication errors in the homes of children with chronic conditions. … November 16, 2022 Significant and sustained reduction in chemotherapy errors through

2272. Tubing safety in the obstetric setting: preventing medication errors. | PSNet
      psnet.ahrq.gov/issue/tubing-safety-obstetric-setting-preventing-medication-errors
      November 04, 2020 - Commentary Tubing safety in the obstetric setting: preventing medication errors. … Tubing safety in the obstetric setting: preventing medication errors. … Tubing safety in the obstetric setting: preventing medication errors. … November 12, 2014 Families as partners in hospital error and adverse event surveillance … fall prevention in a nursing home.

2273. Eight-year experience with a neurosurgical checklist. | PSNet
      psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
      September 27, 2023 - A 6-item checklist was successfully implemented and used in more than 99% of neurosurgical cases over … June 3, 2020 Quality Improvement in Neurosurgery. … November 14, 2012 Side errors in neurosurgery. … September 15, 2010 Wrong-site sinus surgery in otolaryngology. … May 26, 2010 Third wrong-sided brain surgery at R.I. hospital.

2274. Patient Safety Awareness Week | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/news-events/psaw-2021/index.html
      July 01, 2022 - He describes AHRQ's commitment to improving patient safety and its recent work in this area of health …   Register for a complimentary webcast hosted by the Health Resources & Services Administration in … Learn more about AHRQ's work in Patient Safety and Quality Improvement . … Toolkit To Improve Antibiotic Use in Acute Care Hospitals .

2275. Examples of Hospital Quality Measures for Consumers | Agency for Healthcare Research and Quality
      www.ahrq.gov/talkingquality/measures/setting/hospitals/examples.html
      March 01, 2016 - Examples of Hospital Quality Measures for Consumers From the available set of hospital measures … Efficiency Measures Utilization of hospital services or procedures as measured by the hospital discharge … scores with information that serves as a proxy for costs, such as the average amount that insurers pay hospitals … Also in "Measures of Hospital Quality" Examples of Hospital Quality Measures for Consumers Major … Hospital Measurement Sets Databases Used for Hospital Quality Measures

2276. Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal. | PSNet
      psnet.ahrq.gov/issue/determining-safety-office-based-surgery-what-10-years-florida-data-and-6-years-alabama-data
      October 04, 2011 - January 12, 2012 Reducing falls in hospitalized children and adolescents with cancer … a West Virginia hospital. … March 17, 2021 Patient safety in the office-based setting. … checklist useful in a broad practice? … October 13, 2010 Detecting adverse events in dermatologic surgery.

2277. Strategy 3: Bedside Shift Report (Tool 3)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy3/strat3_tool_3_pres_video_508.pptx
      July 23, 2010 - For example, in our hospital, we provide opportunities for patients and family members to be involved … : Patient safety and quality Improved communication Decrease in hospital-acquired complications Patient … patient falls during change of shift, dropping from one to two patient falls per month to one patient … After implementing bedside shift report, hospitals reported an increase in patient satisfaction scores … Hospital staff and patients know about different things in the hospital and may not always be on the

2278. The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications | PSNet
      psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
      July 23, 2024 - in practice and high rates of potentially inappropriate use in ten HMS hospitals. 7 Obtaining ID physician … An earlier survey of ten Michigan hospitals found that there was significant variation in clinical practice … For example, 47% of the respondents indicated that 10–25% of PICCs inserted in their hospitals might … Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update … May 31, 2023 Patient Safety Innovations Preventing Falls

2279. Classics and Emerging Classics | PSNet
      psnet.ahrq.gov/classics
      August 01, 2023 - ) Medical Complications (93) Nosocomial Infections (50) Patient Falls … (691) Children's Hospitals (20) General Hospitals (210) Emergency … their hospitals. … hospitals: a systematic review. … in reducing controlled substance medication errors in hospitals.

2280. Improving the Safety and Quality of Health Care: The Impact of the National Academy of Medicine on Research and Collaboration (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/dzau-summit2016.pdf
      September 28, 2016 - US hospitals each year as a result of preventable medical errors • Errors cost $17 billion – $29 billion … per year in hospitals in the US However, more recent data indicate that these numbers may be substantially … by hospital patients over the 4 years • Nearly 87,000 fewer patients died in the hospital as a result … Pressure Ulcers Catheter Associated Urinary Tract Infections Surgical Site Infections Falls … Discharge Program (2008) Designing Hospitals for Safety and Quality Engaging Patients and Families