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2301. Pressure Injury Prevention in Hospitals Training Program. | PSNet
      psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
      May 01, 2017 - Multi-use Website Pressure Injury Prevention in Hospitals Training Program. … Citation Text: Pressure Injury Prevention in Hospitals Training Program. … Pressure ulcers are a common hospital-acquired condition that can lead to patient harm . … Hospitals Training Program. … March 7, 2018 Fall Prevention in Hospitals Training Program.

2302. Avoidable mistakes rise despite hospital efforts. | PSNet
      psnet.ahrq.gov/issue/avoidable-mistakes-rise-despite-hospital-efforts
      September 27, 2016 - Citation Text: Avoidable mistakes rise despite hospital efforts. Colliver V. … December 23, 2012 Never events: Utah hospitals saw nearly 60 serious errors in 2007. … July 23, 2008 Hospitals to tear up bills for medical mistakes. … February 13, 2008 Many Mass. hospitals will pay for errors. … General Internal Medicine Hospital Medicine Surgery View More

2303. Bad hospital design is making us sicker. | PSNet
      psnet.ahrq.gov/issue/bad-hospital-design-making-us-sicker
      March 30, 2016 - Implementing design changes in care environments can improve patient safety. … March 30, 2016 Reducing preventable harm in hospitals. … February 12, 2016 A night in the hospital, from both ends of the stethoscope. … September 27, 2016 Hospitals target risks of color wristbands. … June 22, 2011 Never events: Utah hospitals saw nearly 60 serious errors in 2007.

2304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49615/psn-pdf
      December 01, 2010 - is not unusual: in acute care hospitals, pressure ulcer incidence after hip fracture ranges from 36.1% … risk factors contribute to the development of pressure ulcers in the hospital, many of which occur in … Changes in CMS reimbursement (not paying for pressure ulcers that develop in the hospital) are based … Not all pressure ulcers are avoidable, but every pressure ulcer occurring in hospitals today should provide … What was their mobility and functional status prior to the fall, including any prior falls or hospitalizations

2305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35009/psn-pdf
      May 27, 2011 - guidelines for administering psychotropic medication to elderly patients at a tertiary care academic hospital … prescription of recommended doses, decreased prescription of nonrecommended drugs, and fewer inpatient falls

2306. What is the medication iatrogenic risk in elderly outpatients for chronic pain? | PSNet
      psnet.ahrq.gov/issue/what-medication-iatrogenic-risk-elderly-outpatients-chronic-pain
      February 12, 2020 - English hospital organizations? … Initiative to deprescribe high-risk drugs for older adults presenting to the emergency department after falls … older people prior to a potentially preventable drug-related hospital admission. … July 20, 2022 Prevalence of potentially inappropriate prescribing in older people in … primary care and its association with hospital admission: longitudinal study.

2307. Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia. | PSNet
      psnet.ahrq.gov/issue/functional-decline-associated-polypharmacy-and-potentially-inappropriate-medications
      June 13, 2018 - Functional decline associated with polypharmacy and potentially inappropriate medications in … older adults with a history of falls: a qualitative study. … November 4, 2020 Hospital-acquired functional decline and clinical outcomes in older … March 2, 2022 Patient factors and hospital outcomes associated with atypical presentation … in hospitalized older adults with COVID-19 during the first surge of the pandemic.

2308. Clinical Issues Series. | PSNet
      psnet.ahrq.gov/issue/clinical-issues-series
      July 05, 2006 - September 1, 2010 Failure to rescue in neonatal care. … human factors methods to ensure appropriate infant identification and abduction prevention within the hospital … unique patient-safety challenge in obstetrics. … September 23, 2020 View More Related Resources Special Issue on Falls … in perinatal settings.

2309. Classifying laboratory incident reports to identify problems that jeopardize patient safety. | PSNet
      psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety
      May 13, 2020 - The investigators describe a system for classifying errors in clinical laboratories. … May 1, 2019 Report on the Safe Use of Pick Lists in Ambulatory Care Settings. … Doctors and Accountability in the Information Age. … May 13, 2015 Man falls off surgical table; St. Joseph's Hospital sued. … March 18, 2010 Patient safety and error reduction in surgical pathology.

2310. Teamwork and Communication. | PSNet
      psnet.ahrq.gov/issue/teamwork-and-communication
      February 06, 2019 - Articles in this special supplement outline tactics to improve communication including crew resource … December 15, 2010 Diagnostic error in acute care. … July 18, 2018 Medication assessment: one determinant of falls risk. … 2011 Outcomes of classroom-based team training interventions for multiprofessional hospital … ; assessment and impact on the first 32 facilities in the programme.

2311. Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions. | PSNet
      psnet.ahrq.gov/issue/mix-wrong-route-administration-bladder-irrigation-intravenous-iv-infusions
      March 27, 2005 - Related Resources From the Same Author(s) National Center for Patient Safety Falls … December 12, 2012 Safety climate associated with adverse events in nursing homes: a national … a VA hospital: design and outcomes. … December 24, 2014 TIPS (Topics in Patient Safety). … April 16, 2018 VA Interprofessional Fellowship Program in Patient Safety.

2312. Support and recovery strategies for second victims. | PSNet
      psnet.ahrq.gov/issue/support-and-recovery-strategies-second-victims
      January 19, 2022 - Clinicians involved in medical errors can be psychologically affected by the experience and they can … January 19, 2022 Safety work and risk management as burdens of treatment in primary care … August 16, 2023 Using potentially preventable severe maternal morbidity to monitor hospital … November 9, 2022 Root cause analysis of reported patient falls in ORs in the Veterans … March 27, 2024 Creating a just culture in the perioperative setting.

2313. The Medication Metronome Project - 2012 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/medication-metronome-project/annual-summary/2012
      January 01, 2012 - Organization Massachusetts General Hospital Funding Mechanism PAR: HS08-270: Utilizing … However, national and local data indicate that the United States health care system is falling significantly … randomized controlled trial using an existing electronic health record (EHR) at Massachusetts General Hospital … in April 2012. … This resulted in 22 PCPs in each study arm.

2314. The Medication Metronome Project - 2011 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/medication-metronome-project/annual-summary/2011
      January 01, 2011 - Organization Massachusetts General Hospital Funding Mechanism PAR: HS08-270: Utilizing … However, national and local data indicate that the United States health care system is falling significantly … short of evidence-based goals for these three conditions, both in terms of risk-factor control and in … The Medication Metronome Project is testing a model of chronic disease medication management in which … randomized controlled trial using an existing electronic health record (EHR) at Massachusetts General Hospital

2315. The value of library and information services in patient care: results of a multisite study. | PSNet
      psnet.ahrq.gov/issue/value-library-and-information-services-patient-care-results-multisite-study
      April 24, 2018 - Study The value of library and information services in patient care: results of a … The value of library and information services in patient care: results of a multisite study. … The value of library and information services in patient care: results of a multisite study. … hospital error and adverse event surveillance. … April 24, 2018 Optimizing Pediatric Patient Safety in the Emergency Care Setting.

2316. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. | PSNet
      psnet.ahrq.gov/issue/safety-culture-healthcare-review-concepts-dimensions-measures-and-progress
      November 21, 2014 - Review Safety culture in healthcare: a review of concepts, dimensions, measures and … Safety culture in healthcare: a review of concepts, dimensions, measures and progress. … Safety culture in healthcare: a review of concepts, dimensions, measures and progress. … November 21, 2014 Utilization of the Seniors Falls Investigation Methodology to identify … system-wide causes of falls in community-dwelling seniors.

2317. Designing a Scorecard for Sustainability: Slide Presentation | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/sustainability/scorecard-slides.html
      December 01, 2017 - Consider participating in surgical morbidity and mortality conferences. … Stability: Has turnover in key positions affected your progress? … How many subgroup meetings held in past six months? … Defects: How many defects have you learned from in past 6 months? … Safety Culture: Average percent positive scores for Safety Climate Domain from most recent Hospital Survey

2318. Trend analysis of radiation therapy incidents over seven years. | PSNet
      psnet.ahrq.gov/issue/trend-analysis-radiation-therapy-incidents-over-seven-years
      December 20, 2023 - Related Resources From the Same Author(s) Interventions to promote safety culture in … December 20, 2023 Overnight stay in the emergency department and mortality in older patients … Effect of sleep deprivation after a night shift duty on simulated crisis management by residents in … severe adverse events in the adult medical intensive care unit: a seven-year prospective study. … November 7, 2018 Mortality due to hospital-acquired infection after cardiac surgery.

2319. Should patients have a role in patient safety? A safety engineering view. | PSNet
      psnet.ahrq.gov/issue/should-patients-have-role-patient-safety-safety-engineering-view
      June 10, 2009 - Commentary Should patients have a role in patient safety? … Should patients have a role in patient safety? A safety engineering view. … Should patients have a role in patient safety? A safety engineering view. … and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists. … July 1, 2020 Diagnostic Error in Medicine.

2320. Enhancing Surgical Team Communication: SOPS® and TeamSTEPPS®in Action Webcast - Closing (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/06-sops-teamstepps-webcast-closing.pdf
      January 01, 2022 - A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals … Does teamwork improve performance in the operating room? A multilevel evaluation. … Impact of TeamSTEPPS on patient safety culture in a Swiss maternity ward. … Submitted to Frontiers in Health Services. … Mitchell C, Mazur L, et al., Analysis of patient safety even report categories at one large academic hospital