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2341. Postdischarge adverse events among neonates admitted to the neonatal intensive care unit. | PSNet
      psnet.ahrq.gov/issue/postdischarge-adverse-events-among-neonates-admitted-neonatal-intensive-care-unit
      October 05, 2022 - including procedural complications and adverse drug events) and subsequent emergency department visits or hospital … Post-discharge adverse events among African American and Caucasian patients of an urban community hospital … July 31, 2013 Validation of the second victim experience and support tool-revised in … review of root cause analyses of falls leading to adverse events. … intensive care unit: the behavioral impact of in situ simulation.

2342. Final Progress Report: The Value of Hospital-Related Patient-Safety Interventions to Key Stakeholders (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/nuckols-report.pdf
      January 01, 2024 - incentives that reach up to several million dollars per hospital, about half of small and medium hospitals … Conclusions: In hospital-related settings, implementing CPOE is associated with >50% decline in patient … Acute Care Hospitals” is under review at Value in Health. … Individualizing Assessments of Risk to Reduce Falls in UC Hospitals. … Adoption of health information technology for medication safety in U.S. Hospitals, 2006.

2343. Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. | PSNet
      psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
      November 15, 2023 - Use By Other Organizations The Hospital at Home program has been adopted by 41 hospitals, health … At Home program, which expanded on the “Hospitals Without Walls” program implemented in response to … In addition, hospitalized seniors are at risk of falls, fractures, and medical/medication errors. 2 … complications such as delirium and falls), urinary catheters, or chemical or physical restraints and … Hospital at home versus in-patient hospital care.

2344. Organizational Embrace of CUSP to Improve Patient Safety (Slide Presentation) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/org-embrace-slides/slides.html
      June 01, 2013 - Holy Cross Hospital Slide 5. Agenda Slide 6. Holy Cross Hospital Slide 7. … Objectives To relate an organization’s approach to implementing CUSP in multiple areas of the hospital … Holy Cross Hospital Member of Trinity Health Largest hospital in MD-DC suburbs: Founded 1963 … Upper Chesapeake Health, Maryland Two acute care, not-for-profit hospitals -- Upper Chesapeake … Medical Center in Bel Air and Harford Memorial Hospital in Havre de Grace, 30-40 miles northeast of Baltimore

2345. Patient-centered prescription opioid tapering in community outpatients with chronic pain. | PSNet
      psnet.ahrq.gov/issue/patient-centered-prescription-opioid-tapering-community-outpatients-chronic-pain
      May 17, 2017 - Emerging Classic Patient-centered prescription opioid tapering in … Patient-Centered Prescription Opioid Tapering in Community Outpatients With Chronic Pain. … a multistate hospital network--13 academic medical centers, April-June 2020. … January 29, 2020 Unsafe care in residential settings for older adults. … older adults with a history of falls: a qualitative study.

2346. Final Progress Report: Proactive Risk Assessment of Primary Care of the Elderly (pdf file)
      www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
      January 01, 2024 - Patient gets dizzy after first dose, falls, breaks hip and ends up in nursing home for rest of life. … Patient gets dizzy after first dose, falls, hits head, resulting in subdural hematoma. … Patient gets dizzy after first dose, falls, sprains dominant hand/wrist, needs in-home care for 2 weeks … In fact, a recent meta-analysis of primary care interventions to reduce ADEs and hospital admissions … Beyond the Hospital: Human Factors and Ergonomics Issues in the Ambulatory/Outpatient Care Setting.

2347. Mismanagement of Delirium | PSNet
      psnet.ahrq.gov/web-mm/mismanagement-delirium
      February 13, 2014 - By history, this patient exhibited features of parkinsonism (shuffling gait and falls), disturbed nighttime … Instead, the patient was transferred to the hospital emergency department, spending an entire night in … impairment Advancing age (> 65 years) History of delirium, stroke, neurological disease, falls … February 13, 2014 Families as partners in hospital error and adverse event surveillance … Worst Headache July 1, 2004 View More See More About The Topic Hospitals

2348. Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
      January 01, 2023 - psychiatric disorder in the hospital setting … bridle securement device may have prevented dislodgement of the first NGT. – After events of this type, hospitals … every US hospital. … the hospital setting and is safe in most cases, but there can be serious complications such as esophageal … I-DECIDED®—A decision tool for assessment and management of invasive devices in the hospital setting.

2349. Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative. | PSNet
      psnet.ahrq.gov/issue/outcomes-wake-safe-pediatric-anesthesia-quality-improvement-initiative
      December 22, 2018 - October 7, 2020 Communication failures contributing to patient injury in anaesthesia … fall prevention in a nursing home. … December 11, 2024 Fire safety in the operating room. … the operating room setting in a tertiary academic center. … a paediatric hospital.

2350. Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level. | PSNet
      psnet.ahrq.gov/issue/patient-safetys-missing-link-using-clinical-expertise-recognize-respond-and-reduce-risks
      May 08, 2017 - May 27, 2020 Root cause analysis of reported patient falls in ORs in the Veterans Health … January 18, 2013 Prevalence and causes of diagnostic errors in hospitalized patients … April 12, 2023 The effect of bedrails on falls and injury: a systematic review of clinical … April 11, 2011 The Quality in Australian Health Care Study. … May 22, 2019 Walking the tightrope: communicating overdiagnosis in modern healthcare.

2351. Safe Administration of Medication in School: Policy Statement. | PSNet
      psnet.ahrq.gov/issue/safe-administration-medication-school-policy-statement
      May 31, 2023 - Organizational Policy/Guidelines Safe Administration of Medication in School: Policy … Safe Administration of Medication in School: Policy Statement. … Safe Administration of Medication in School: Policy Statement. … January 6, 2017 Families as partners in hospital error and adverse event surveillance … children and adolescents in outpatient settings: clinical practice guideline.

2352. Exploring how nursing schools handle student errors and near misses. | PSNet
      psnet.ahrq.gov/issue/exploring-how-nursing-schools-handle-student-errors-and-near-misses
      May 28, 2014 - Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in … The attitudes of nursing students and clinical instructors towards reporting irregular incidents in … Seeing through Google Glass: using an innovative technology to improve medication safety behaviors in … March 13, 2014 Learning in action: developing safety improvement capabilities through … October 19, 2011 View More See More About The Topic Hospitals Nurses

2353. Seen through the patients' eyes: safety of chronic illness care. | PSNet
      psnet.ahrq.gov/issue/seen-through-patients-eyes-safety-chronic-illness-care
      May 16, 2018 - falls , adverse drug events , and errors in diagnosis or treatment. … An extensive evaluation of safety culture in a radiotherapy institute. … June 14, 2019 Intensive care medicine in 2050: preventing harm. … May 1, 2019 The global burden of diagnostic errors in primary care. … January 31, 2013 Preventing communication errors in telephone medicine.

2354. Children's hospitals' solutions for patient safety collaborative impact on hospital-acquired harm. | PSNet
      psnet.ahrq.gov/issue/childrens-hospitals-solutions-patient-safety-collaborative-impact-hospital-acquired-harm
      August 10, 2022 - safety collaborative impact on hospital-acquired harm. … Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm. … Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm. … in children's hospitals. … a children's hospital.

2355. Malnutrition in Hospitalized Adults: A Systematic Review. | PSNet
      psnet.ahrq.gov/issue/malnutrition-hospitalized-adults-systematic-review
      December 21, 2022 - Book/Report Malnutrition in Hospitalized Adults: A Systematic Review. … Citation Text: Malnutrition in Hospitalized Adults: A Systematic Review. … provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital … September 29, 2017 View More See More About The Topic Hospitals Health … Care Executives and Administrators Facility and Group Administrators Nutrition/Dietetics Hospital

2356. Communicating uncertainty: a narrative review and framework for future research. | PSNet
      psnet.ahrq.gov/issue/communicating-uncertainty-narrative-review-and-framework-future-research
      February 24, 2021 - explaining contingency plans as strategies for effective discussions when uncertainty is present in … May 25, 2022 Omissions of care in nursing homes: a uniform definition for research and … and Quality April 26, 2023 Towards conceptualizing patients as partners in … April 21, 2021 The patient died: what about involvement in the investigation process? … June 24, 2020 A systematic review of falls in hospital for patients with communication

2357. Scoping review of studies evaluating frailty and its association with medication harm. | PSNet
      psnet.ahrq.gov/issue/scoping-review-studies-evaluating-frailty-and-its-association-medication-harm
      May 25, 2022 - Download Citation Related Resources From the Same Author(s) Opioids and falls … risk in older adults: a narrative review. … February 16, 2022 Drug-drug interactions and prescription appropriateness at hospital … September 28, 2022 Medication errors and processes to reduce them in care homes in the … coordination reported in a national study of older US adults.

2358. 15 Crosscutting Potential High Impact 2012-12-11 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/15_crosscutting_potential_high_impact_2012-12-11.pdf
      January 01, 2012 - Rural Areas Primary care access in rural and remote regions is limited by physician shortages, hospital … If the onus of improving patient adherence falls on the provider, staffing needs might increase because … One clinical expert claims, “Most hospitals and ERs don’t want these patient[s] anyway. … The hospital also states that the care team at the center includes (in addition to physicians) a geriatric … hospital claims that unit staff receive training in both geriatrics and communication with elderly

2359. High-Priority Evidence Gaps for Clinical Preventive Services (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/annlrpt2013%20(4).pdf
      November 01, 2013 - Preventing Falls and Fractures Falls are the leading cause of injury in adults age 65 and older: about … She is a general internist and attending physician at San Francisco General Hospital and the director … of the UCSF Center for Vulnerable Populations at San Francisco General Hospital. … at Increased Risk for Falls The USPSTF recommends exercise or physical therapy to prevent falls in … at Increased Risk for Falls The USPSTF recommends vitamin D supplementation to prevent falls in community-dwelling

2360. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865484/psn-pdf
      April 03, 2024 - In this study, records of patients with incidental imaging findings (IIF) were reviewed to determine … if IIFs were included on hospital discharge summaries and if the patients were aware of them.