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2321. McAlearney, Ann Scheck | Digital Healthcare Research
      digital.ahrq.gov/principal-investigator/mcalearney-ann-scheck
      January 01, 2023 - McAlearney, Ann Scheck Understanding secure messaging in the inpatient … Understanding secure messaging in the inpatient environment: a new avenue for communication and patient … Principal Investigator McAlearney, Ann Scheck Project Name Portals in Inpatient Care: … An exploration of the association between inpatient access to tablets and patient satisfaction with hospital … An exploration of the association between inpatient access to tablets and patient satisfaction with hospital

2322. A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet
      psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional
      March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause … review of root cause analyses of falls leading to adverse events. … 6, 2022 Root cause analysis to identify contributing factors for the development of hospital … August 22, 2016 Measuring patient safety in the emergency department. … November 13, 2013 Improving handoffs in the emergency department.

2323. Therapeutic errors involving adults in the community setting: nature, causes and outcomes. | PSNet
      psnet.ahrq.gov/issue/therapeutic-errors-involving-adults-community-setting-nature-causes-and-outcomes
      May 24, 2009 - residents in Victoria, Australia. … hospital practice: factors associated with turnover, outcomes, and patient safety. … July 24, 2013 The effect of medication reconciliation in elderly patients at hospital … March 4, 2011 The patient who falls: "It's always a trade-off." … long-term care facilities in Germany.

2324. Privacy Gone Awry | PSNet
      psnet.ahrq.gov/web-mm/privacy-gone-awry
      February 24, 2011 - In preparation for an upcoming JCAHO inspection, the small community hospital (which had suffered from … monitoring device, we should have an alarm ( 19 ) for automatically indicating when that parameter falls … would inconvenience the patient's family and represent a potential revenue loss for the surgeon and the hospital … Cuff May 1, 2003 View More See More About The Topic General Hospitals … Children's Hospitals Health Care Providers Pediatrics Surgery View More

2325. Introducing the Child HCAHPS® Survey Database webcast-Rubin (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/child-hcahps-steps-participation.pdf
      May 20, 2022 - collected between January – December 2021 will be accepted • Reporting products anticipated for release in … Data Submission Process • Hospitals interested in submitting data complete four easy steps: Register … The 2022 CAHPS Child Hospital Survey Data Submission System is now closed Participation in the CAHPS … Child Hospital Survey Database is open to hospital is that administer the CAHPS Child Hospital Survey … CAHPS Child Hospital Data Submission Data Confidentiality • Participating hospitals can be assured

2326. Making Healthcare Safer IV: Summary of Findings, 2023-2024 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-1-year-final-report-updated-title_0.pdf
      May 01, 2024 - adults in pre-hospital, ED, or hospital-wide settings. … o Most studies found no reduction in falls, but a systematic review reported that half of the included … studies reduced falls. … fall prevention programs and found reduced falls. … Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

2327. Sterile compounding: clinical, legal, and regulatory implications for patient safety. | PSNet
      psnet.ahrq.gov/issue/sterile-compounding-clinical-legal-and-regulatory-implications-patient-safety
      March 20, 2024 - 2013, resulting in more than 60 deaths. … May 15, 2024 Reduced postdischarge incidents after implementation of a hospital-to-home … December 11, 2024 Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based … July 22, 2020 Reducing falls with a safety spotter program. … January 23, 2019 Community-acquired and hospital-acquired medication harm among older

2328. Toolkit for Using the AHRQ Quality Indicators - A “How to” Guide for Improving Hospital Quality and Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
      December 01, 2017 - Hospitals Guide to Patient and Family Engagement in Hospital Quality and Safety Preventing Falls … in Hospitals Hospital Survey on Patient Safety Culture Comprehensive Unit-based Safety Program ( … -­‐10 2016 version tested with 20 hospitals – In-depth evaluation with 6 hospitals Slide … hospitals if available Can help identify which QIs the hospital may need to address for quality … Acute care hospitals treat about 2.5 million pressure ulcers each year, and as many as 15% of hospital

2329. Devastatingly human: an analysis of registered nurses' medication error accounts. | PSNet
      psnet.ahrq.gov/issue/devastatingly-human-analysis-registered-nurses-medication-error-accounts
      June 27, 2018 - Exploring organizational context and structure as predictors of medication errors and patient falls … hospital practice: factors associated with turnover, outcomes, and patient safety. … September 27, 2016 Role of relatives of ethnic minority patients in patient safety in … hospital care: a qualitative study. … are in jeopardy.

2330. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849660/psn-pdf
      May 31, 2023 - Errors in care and adverse events associated with health literacy include mistakes in diabetes management … for children;3  incorrect use of inhalers and aerosol medications;4 falls; delays in receiving treatment … generic (e.g., Health Literate Health Care Organization-106 or the Health Literacy Environment of Hospitals … Have processes in place to review materials with patients. … high risk situation such as when patients are prescribed medications or are discharged from the hospital

2331. Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study. | PSNet
      psnet.ahrq.gov/issue/antimicrobial-residual-drug-error-intensive-care-unit-single-blinded-prospective
      November 21, 2021 - As with all medications, delays in or underdosing of  antimicrobials can result in unnecessarily long … hospital stays. … May 18, 2022 Clinical impact and economic burden of hospital-acquired conditions following … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls … View More See More About The Topic Intensive Care Units Critical Care Nursing Hospital

2332. Diagnostic Errors Case Studies | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
      August 10, 2025 - An elderly man had iron deficiency anemia with progressively falling … The patient was admitted to the hospital with gastrointestinal symptoms and diagnosed with cholecystitis … ED for a third time, where has was evaluated and involuntarily admitted to an inpatient psychiatric hospital … Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from … Linkedin Copy URL An elderly man had iron deficiency anemia with progressively falling

2333. References | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-reimagining-healthcare-teams-refs.html
      July 01, 2023 - Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015. … Automated loss-of-balance event identification in older adults at risk of falls during real-world walking … Artificial intelligence and human trust in healthcare: focus on clinicians. … Why physicians should trust in patients. … FDA regulation of predictive clinical decision-support tools: what does it mean for hospitals?

2334. The prevalence and impact of potentially inappropriate prescribing among older persons in primary care settings: multilevel meta-analysis. | PSNet
      psnet.ahrq.gov/issue/prevalence-and-impact-potentially-inappropriate-prescribing-among-older-persons-primary-care
      July 24, 2019 - patient safety and reducing medical errors in hospital settings: a narrative review. … June 22, 2009 Reduction in hospital-wide clinical laboratory specimen identification … drug-related hospital admissions? … older adults with a history of falls: a qualitative study. … September 29, 2017 Mistakes We Make in Dialysis.

2335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47847/psn-pdf
      July 10, 2024 - July 10, 2024 California Hospital Patient Safety Organization: Sacramento, CA; 2024. … Sections of the report include high-level review of falls and inequities, medication safety issues, syphilis

2336. There is a vulnerable group we must not leave behind in our response to COVID-19: people who are dependent on illicit drugs. | PSNet
      psnet.ahrq.gov/issue/there-vulnerable-group-we-must-not-leave-behind-our-response-covid-19-people-who-are
      October 05, 2022 - Newspaper/Magazine Article There is a vulnerable group we must not leave behind in … August 25, 2021 Interventions to prevent falls in older adults: updated evidence report … effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital … in patients with polypharmacy. … July 29, 2020 Special report: COVID deepens the other opioid crisis - a shortage of hospital

2337. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33766/psn-pdf
      May 01, 2014 - To be compared from one hospital to another in particular, or even from one ward to another in the same … We have much experience with monitoring this tool and it has been used in more than 5000 hospitals worldwide … 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 … to generalize from the hand hygiene experience to let's say trying to decrease falls or medication

2338. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
      August 01, 2014 - credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hospital … Necrotizing Fasciitis A 49-year-old previously healthy man presented to the emergency department (ED) after falling … of erysipelas Since then, numerous terms have been applied to this condition—phagedena gangrenosum, hospital … Investigation upon the nature, causes, and treatment of hospital gangrene, as it prevailed in the confederate … one study, they were present in only 43% of patients with NF Fever may not be present In one review,

2339. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? | PSNet
      psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and
      June 16, 2021 - patient safety in the NHS. … July 3, 2014 Do falls and other safety issues occur more often during handovers when … June 29, 2022 Why do hospital prescribers continue antibiotics when it is safe to stop … October 15, 2014 Patient involvement in medication safety in hospital: an exploratory … July 16, 2014 Speaking up for patient safety by hospital-based health care professionals

2340. Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study. | PSNet
      psnet.ahrq.gov/issue/strategies-safe-interhospital-transfer-intubated-patient-or-where-readiness-intubation-needed
      July 31, 2013 - November 2, 2022 Teamwork is associated with reduced hospital staff burnout at military … May 31, 2023 Patient Safety Innovations Preventing Falls … February 6, 2019 Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired … catheter-associated urinary tract infections in intensive care units. … May 25, 2011 Worries and concerns experienced by nurse specialists during inter-hospital