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2381. Treatment Challenges After Discharge | PSNet
      psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
      January 03, 2017 - Appreciate the unique challenges posed by transition in care from the hospital to outpatient physician … Even if the transfer of care is done poorly, the patient still is in the hospital and is surrounded by … Furthermore, hospital-based care teams and primary care physicians often exist in different health care … Emergency department visits by persons recently discharged from U.S. hospitals. … Related Resources Patient Safety Innovations Preventing Falls

2382. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39946/psn-pdf
      October 20, 2023 - October 20, 2023 Okemos, MI: Michigan Health & Hospital Association. … The achievements noted in the 2022-2023 data review include reduction both fall and blood- or blood-product

2383. The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center. | PSNet
      psnet.ahrq.gov/issue/nature-reported-safety-events-related-care-coordination-operating-room-setting-tertiary
      May 11, 2022 - The nature of reported safety events related to care coordination in the operating room setting in a … In the perioperative setting of one hospital, insufficient handoffs were  the most common event type … The nature of reported safety events related to care coordination in the operating room setting in a … Download Citation Related Resources From the Same Author(s) Patient falls … September 13, 2017 Factors related to serious safety events in a children's hospital

2384. Identifying boundary spanning reporter roles in patient safety events. | PSNet
      psnet.ahrq.gov/issue/identifying-boundary-spanning-reporter-roles-patient-safety-events
      December 07, 2022 - Identifying boundary spanning reporter roles in patient safety events. … Identifying boundary spanning reporter roles in patient safety events. … review of root cause analyses of falls leading to adverse events. … March 13, 2024 Middle manager responses to hospital co-workers' unprofessional behaviours … among various hospital-based healthcare professionals and trainees in a simulated patient room.

2385. A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries | PSNet
      psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
      July 23, 2024 - There is tremendous variation in hospital care, with low-risk cesarean rates ranging from 2.4% to 36.5% … across hospitals. 4 These variations are attributed to hospital and provider factors as well as to … across states, ranging from roughly 18% to 30.9% in 2021. 5,6 In 2016, 24 hospitals (the first of three … ) participated in the program. 9 Compared with hospitals that were not participating in, or exposed … July 23, 2024 Patient Safety Innovations Preventing Falls

2386. Omissions of care in nursing home settings: a narrative review. | PSNet
      psnet.ahrq.gov/issue/omissions-care-nursing-home-settings-narrative-review
      November 18, 2020 - Omissions of care in nursing home settings: a narrative review. … omissions of care, and identified nineteen event types, with the most common being all-cause mortality, falls … Omissions of care in nursing home settings: a narrative review. … March 3, 2021 A multi-hospital before–after observational study using a point-prevalence … August 5, 2015 Medication safety in a psychiatric hospital.

2387. Appendix L. Intensive Care Unit Infographic Poster | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-l.html
      October 01, 2015 - Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide … Hospital Units: Implementation Guide Overview Frameworks for Change and Improvement Technical … "All immobile patients need a urinary catheter to prevent hospital-acquired pressure ulcers." … risk of Clostridium difficile infection, immobility (Foley is considered a "one-point restraint), hospital-acquired … pressure ulcers, falls, and venous thromboembolism. 2 , 3 Not all critically ill, immobile patients

2388. Eptifibatide Epilogue | PSNet
      psnet.ahrq.gov/web-mm/eptifibatide-epilogue
      March 04, 2011 - 2005, the Joint Commission issued a National Patient Safety Goal requiring hospitals to standardize … Many hospitals have implemented systems designed to comply with the Joint Commission requirement, such … The National Quality Forum also recommends that hospitals establish organization-wide approaches to team … If users program an infusion rate that falls outside of approved ranges (i.e., over-doses or under-doses … Patient safety and computerized medication ordering at Brigham and Women's Hospital.

2389. The standardisation of handoffs in a large academic paediatric emergency department using I-PASS. | PSNet
      psnet.ahrq.gov/issue/standardisation-handoffs-large-academic-paediatric-emergency-department-using-i-pass
      October 21, 2020 - The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. … hospital. … in patient safety. … March 8, 2023 Using human factors and ergonomics principles to prevent inpatient falls … December 22, 2021 Results and lessons from a hospital-wide initiative incentivised by

2390. Use of Patient Buddy Application to Disseminate Knowledge & Prevent Readmission - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024004-bajaj-final-report-2017.pdf
      January 01, 2017 - Patients are often re-admitted for HE, falls, infections and ascites-related issues. … apps, which can communicate problems that can be handled before they need an emergent visit to the hospital … The reason for hospitalization was anasarca in 10, HE in 10, GI bleeding in 9, infections in 3, hepatic … hydrothorax in 2 and cirrhosis-unrelated conditions in 5 patients (Table 2). … they were already on assistive walking devices and had counseling regarding falls before).

2391. Patients' perception of types of errors in palliative care—results from a qualitative interview study. | PSNet
      psnet.ahrq.gov/issue/patients-perception-types-errors-palliative-care-results-qualitative-interview-study
      December 04, 2016 - Adverse events in palliative care differ from those in other environments. … December 4, 2016 Situation awareness errors in anesthesia and critical care in 200 cases … a multistate hospital network--13 academic medical centers, April-June 2020. … April 10, 2019 Adequacy of information transferred at resident sign-out (in-hospital … December 4, 2024 Patient Safety Innovations Preventing Falls

2392. Small and Rural and Critical Access Hospitals (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
      April 01, 2013 - The challenge that we all have, not just about this particular subject, but in hospitals there is always … So again, if you’re looking at falls, you would use the evidence-based practices to prevent falls. … We are a critical access hospital located in the rural southwestern corner of Wisconsin. … In the critical access hospital, we don’t have as much automation as other places. … is in non-critical access hospitals.

2393. The impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses. | PSNet
      psnet.ahrq.gov/issue/impacts-using-community-health-volunteers-coach-medication-safety-behaviors-among-rural
      September 15, 2011 - among elderly patients with chronic illness in a rural area. … 2020 Barriers and facilitators to implementing interventions for reducing avoidable hospital … December 17, 2014 Applying root cause analysis to improve patient safety: decreasing falls … in postpartum women. … March 23, 2011 Out-of-hospital medication errors: a 6-year analysis of the national poison

2394. Measuring the Value of Remote Intensive Care Unit (ICU) Monitoring - 2008 | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/measuring-value-remote-intensive-care-unit-icu-monitoring/annual-summary/2008
      January 01, 2008 - tele-ICUs may have decision support software to help identify subtle trends like rising creatinine and falling … five of the health care system’s hospitals at the time of the study. … severity of the initial diagnosis), as well as on hospital costs. … ICUs in a tertiary care teaching hospital, and in seven community (including two “small”) hospitals … The crude mean hospital LOS for survivors in the pre-tele-ICU group was 9.8 days versus 10.7 days for

2395. Statewide Efforts to Enhance HIT in Critical Access Hospitals (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/2006WardWakefieldLi_051111comp.pdf
      January 01, 2005 - Statewide Efforts to Enhance HIT in Critical Access Hospitals Statewide Efforts to Enhance HIT in …  Primary collaborating organizations are: • Iowa Hospital Association • Iowa Medicare Rural Hospital … - Approach  As part of the AHRQ grant, in Fall 2005 we developed a new survey of Iowa hospital clinical … each hospital Sample for 2005 Survey number of hospitals that responded total number of hospitals … in Rural and Urban Hospitals Current HIT Capabilities �in Rural Hospitals - Summary Electronic Health

2396. ESPEN guideline on hospital nutrition. | PSNet
      psnet.ahrq.gov/issue/espen-guideline-hospital-nutrition
      February 17, 2015 - ESPEN guideline on hospital nutrition. … Mistakes in hospital dietary services can contribute to allergic reactions and patient malnourishment … ESPEN guideline on hospital nutrition. … acute-care hospitals: 2022 Update. … February 13, 2008 View More See More About The Topic Hospitals Allied

2397. Insurers stop paying for care linked to errors. | PSNet
      psnet.ahrq.gov/issue/insurers-stop-paying-care-linked-errors
      January 18, 2023 - October 3, 2017 CA sitting on millions in hospital fines. … May 27, 2009 Medication errors in family practice, in hospitals and after discharge from … the hospital: an ethical analysis. … May 16, 2008 Many Mass. hospitals will pay for errors. … Patients General Internal Medicine Hospital Medicine View More

2398. Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic. | PSNet
      psnet.ahrq.gov/issue/moving-beyond-misuse-and-diversion-urgent-need-consider-role-iatrogenic-addiction-current
      July 18, 2012 - Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in … Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the … A substantial number of drug deaths in the United States have been associated with inadvertent overdose … March 3, 2011 Errors and discrepancies in the administration of intravenous infusions … July 2, 2014 Cost of inpatient falls and cost-benefit analysis of implementation of an

2399. Nursing home patient safety culture perceptions among licensed practical nurses. | PSNet
      psnet.ahrq.gov/issue/nursing-home-patient-safety-culture-perceptions-among-licensed-practical-nurses
      February 17, 2021 - and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working … in other settings. … Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in … fall prevention in a nursing home. … December 9, 2020 Expanding frontiers of risk management: care safety in nursing home

2400. Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department. | PSNet
      psnet.ahrq.gov/issue/situation-background-assessment-and-recommendation-guided-huddles-improve-communication-and
      September 23, 2020 - In an effort to improve communication in an urban emergency department, nurse practitioners and registered … a multistate hospital network--13 academic medical centers, April-June 2020. … October 3, 2012 Overtreatment in the United States. … Diagnostic Safety in the Emergency Department. … June 13, 2018 In situ simulation: detection of safety threats and teamwork training in