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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ulep.pdf
January 01, 2004 - The HFHS is a multifaceted health care provider with a 4-hospital
network (Henry Ford Hospital, a 906 … -bed tertiary care facility; 2 community-
based hospitals; and a 100-bed behavioral hospital). … Ford Hospital and 22
additional Henry Ford medical centers. … Facility A is the main, 906-bed hospital; Facility B represents the community-
based hospitals; Facility … or treatment failures, and they took
on the same importance as the former categories dealing with falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
December 01, 2017 - or EMR, data to make staff aware of residents at risk of adverse events such as pressure ulcers and falls … help prevent four adverse events: pressure ulcers, pressure ulcers that are not healing appropriately, falls … On-Time reports for preventing falls and avoidable hospitalizations are currently in development. … Pressure Ulcer Healing, Falls, and Avoidable Hospitalization reports and worksheets have been tested … is designed to identify residents at risk for the adverse event of interest (e.g., pressure ulcers, falls
-
psnet.ahrq.gov/issue/principles-patient-and-family-partnership-care-american-college-physicians-position-paper
March 14, 2018 - Emerging Classic
Principles for Patient and Family Partnership in … in education of health care professionals. … June 19, 2019
Improving handoffs in the emergency department. … Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital … Related Resources
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/issue/impact-obstetrical-hospitalist-program-safety-events-mid-sized-obstetrical-unit
April 03, 2019 - Study
Impact of an obstetrical hospitalist program on the safety events in a mid-sized … Impact of an obstetrical hospitalist program on the safety events in a mid-sized obstetrical unit. … This article reports on the impact of an OB hospitalist program on serious safety events in one hospital … September 30, 2020
Patient safety incidents describing patient falls in critical care … in North West England between 2009 and 2017.
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psnet.ahrq.gov/issue/blaming-others-threatening-events
November 25, 2009 - Copy Citation
Related Resources From the Same Author(s)
Deaths in Acute Hospitals … October 19, 2022
Morbidity and mortality caused by noncompliance with California hospital … licensure: immediate jeopardies in California hospitals, 2007-2017. … March 15, 2023
Preventable deaths due to problems in care in English acute hospitals: … July 1, 2017
Day passes for vulnerable patients of psychiatric hospitals can have dangerous
-
psnet.ahrq.gov/issue/racism-derails-black-mens-health-even-education-levels-rise
May 28, 2014 - May 28, 2014
Medicare cuts payment to 774 hospitals over patient complications. … June 2, 2021
Medicare failed to investigate suspicious infection cases from 96 hospitals … June 1, 2022
Hospital workers complain of minimal disclosure after COVID exposures. … May 12, 2021
View More
Related Resources
Hospitals in two states … May 31, 2023
Few hospitals are willing to bear the cost of providing psychiatric care
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psnet.ahrq.gov/issue/ahrq-safety-program-mrsa-prevention
December 24, 2008 - Methicillin-resistant Staphylococcus aureus (MRSA) infections are a persistent challenge in hospitals … May 11, 2022
Toolkit for Preventing CLABSI and CAUTI in ICUs. … November 9, 2016
Reducing Unnecessary Hospital Readmissions: The Role of the Patient … October 18, 2011
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See More About The Topic
Hospitals
Long-Term … Care
Health Care Providers
Quality and Safety Professionals
Hospital Medicine
View
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psnet.ahrq.gov/issue/reducing-harm-patients-using-patient-safety-dashboards-board-level
February 22, 2010 - This commentary describes how hospital and health care system board members can develop facility-specific … From the Same Author(s)
The 100,000 Lives Campaign: crystallizing standards of care for hospitals … individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care. … October 19, 2022
Families as partners in hospital error and adverse event surveillance … September 24, 2010
Hospital responses to the Leapfrog Group in local markets.
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psnet.ahrq.gov/issue/preventing-pressure-ulcers-goal-zero
September 30, 2010 - hospital practice: factors associated with turnover, outcomes, and patient safety. … pressure ulcers in a system of community hospitals. … March 7, 2018
HealthGrades Sixth Annual Patient Safety in American Hospitals Study. … October 8, 2008
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See More About The Topic
Hospitals
General … Internal Medicine
Hospital Medicine
Pressure Ulcers
Quality Improvement Strategies
-
psnet.ahrq.gov/issue/day-passes-vulnerable-patients-psychiatric-hospitals-can-have-dangerous-even-fatal
October 29, 2014 - Newspaper/Magazine Article
Day passes for vulnerable patients of psychiatric hospitals … Related Resources From the Same Author(s)
Ebola case raises concern about everyday hospital … September 23, 2020
Bias in the ER. … December 18, 2019
Hospital mistakes kept secret. … of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/impmaterials.html
June 01, 2017 - Hospital Transfer Self-Assessment Worksheet
Purpose
The Hospital Transfer Self-Assessment … gaps in processes or to redesign or streamline processes. … Yes
No
>1 hospitalization or ED visit in the past 3 months
|___|
|___|
>1 fall in the … Reporting subtle changes in conditions
f. … identifying and reporting a change in resident condition?
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T2-Antibiotic_Pocket_Cards.pdf
May 01, 2014 - • Especially consider in residents who received antibiotics
in previous 60 days and have one or more … • Clean contaminated surfaces with EPA-registered
hospital disinfectant. … • Clean contaminated surfaces with EPA-registered hospital
disinfectant. … Nonspecific symptoms or signs not referable to the urinary
tract, such as falls or mental status change … Decubitus ulcer in a resident at the end of life.
12.
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psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2007
April 24, 2007 - Book/Report
Improving America's Hospitals: The Joint Commission's Annual Report on … by hospital and by state. … November 14, 2011
An inpatient fall prevention initiative in a tertiary care hospital … public hospitals. … July 23, 2008
Patient Safety in Canada: An Update.
-
www.ahrq.gov/patient-safety/resources/learning-lab/design-environments-long-desc.html
April 01, 2021 - Assisting in making changes to tones for a new mobile phone platform with SANS and including a new hospital … The IDEA4PS Lab automated surveillance of hospital-acquired infections to provide results in near real … Use preferences for continuous cardiac and respiratory monitoring systems in hospitals: a survey of patients … Clustering and prioritizing patient safety issues during EHR implementation and upgrades in hospital … Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings
-
www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
June 30, 2025 - falls
• 53% reduction in supply issues
• 21% improvement in OR start time
• 30% increase in nursing … all units in hospital
• Hard initiative to implement, especially if you have an open unit and/or no … C. difficile infections in acute care hospitals
45https://www.ahrq.gov/hai/tools.html
https://www.ahrq.gov … a variety of settings and populations
► Acute care hospitals (ICUs and non-ICUs)
► Surgical services … acute care hospitals, long-term care, and
ambulatory care settings.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Cook.pdf
January 01, 2004 - 30
hospitals in a 9-state area of the rural West. … In each
hospital, one team member served as a key contact. … The hospitals that participated
in this research were representative of those found in states with large … A description of
bioethics activities in rural hospitals. … Are health care ethics committees
necessary in rural hospitals?
-
psnet.ahrq.gov/issue/comparing-two-safety-culture-surveys-safety-attitudes-questionnaire-and-hospital-survey
September 01, 2018 - hospital discharge. … June 12, 2013
Clinical risk management in hospitals: strategy, central coordination and … March 11, 2013
An inpatient fall prevention initiative in a tertiary care hospital. … August 10, 2011
Adverse-event-reporting practices by US hospitals: results of a national … April 21, 2010
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See More About The Topic
Hospitals
Risk Managers
-
psnet.ahrq.gov/issue/moving-beyond-readmission-penalties-creating-ideal-process-improve-transitional-care
June 14, 2017 - score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions … September 23, 2020
Preventability and causes of readmissions in a national cohort of … January 25, 2017
Inappropriate medications in elderly ICU survivors: where to intervene … May 8, 2017
Implementation strategies in the context of medication reconciliation: a … February 9, 2011
Announcing 2009 Leapfrog top hospitals.
-
www.ahrq.gov/opioids/health-systems-research.html
July 01, 2021 - older adults who experienced common side effects from opioids (such as constipation, confusion, nausea, falls … Identifying and Testing Strategies for Management of Opioid Use and Misuse In Older Adults
In September … older adults in primary care settings; to support primary care practices in developing and testing innovative … Characterizing Opioid-Related Adverse Events in Older Adults After Hospital Discharge. … Prescribing of opioids at hospital discharge and associated adverse patient outcomes.
-
psnet.ahrq.gov/issue/rural-inpatient-telepharmacy-consultation-demonstration-after-hours-medication-review
January 23, 2017 - a hospital setting? … January 12, 2022
Families as partners in hospital error and adverse event surveillance … December 21, 2014
Medication error reporting in rural critical access hospitals in the … April 5, 2013
Errors in medication history at hospital admission: prevalence and predicting … August 24, 2011
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See More About The Topic
Hospitals
Pharmacists