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psnet.ahrq.gov/node/48130/psn-pdf
August 07, 2019 - Adverse events in long-term care residents transitioning
from hospital back to nursing home. … Adverse Events in Long-term Care Residents Transitioning From
Hospital Back to Nursing Home. … -
home
Transitions from hospitals to long-term care facilities are associated with safety hazards. … Common adverse events included falls, pressure
ulcers, health care–associated infections, and adverse … The authors conclude that improved communication and coordination between
discharging hospitals and
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www.ahrq.gov/hai/pfp/haccost2017-results.html
November 01, 2017 - Only studies of single hospitals or local hospital networks reported consequences of CLABSI for a general … Our search for recent literature on in-hospital falls in the United States returned very few results … addition, many more recent studies that address additional cost due to in-hospital falls base their … finding reliable sources of data on injuries linked exclusively to in-hospital falls. … leading to an admission and falls occurring in the institution.
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psnet.ahrq.gov/issue/nurse-reported-bullying-and-documented-adverse-patient-events-exploratory-study-us-hospital
November 11, 2020 - Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital. … Nurse-reported bullying and documented adverse patient events: an exploratory study in a US Hospital. … June 9, 2021
Evolving factors in hospital safety: a systematic review and meta-analysis … hospitals: a descriptive study. … December 9, 2020
Clinical deterioration and hospital‐acquired complications in adult
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psnet.ahrq.gov/issue/negligence-genuine-error-and-litigation
July 10, 2024 - January 23, 2019
The impact of anti-infective drug shortages on hospitals in the United … April 21, 2015
The effect of health information technology on quality in U.S. hospitals … May 22, 2013
Minnesota Hospital Association Statewide Project: SAFE from FALLS. … October 19, 2012
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries … September 20, 2011
Medicare nonpayment, hospital falls, and unintended consequences.
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psnet.ahrq.gov/node/38760/psn-pdf
July 08, 2009 - Nurses' perceptions of safety culture in long-term care
settings. … Nurses' perceptions of safety culture in long-term care settings. … care facilities are particularly vulnerable to patient safety problems such as
medication errors and falls … Mirroring an issue previously identified in hospitals, nurse managers had a considerably
more optimistic … incidence-adverse-drug-events-two-large-academic-long-term-care-facilities
https://psnet.ahrq.gov/issue/interventions-preventing-falls-acute-and-chronic-care-hospitals-systematic-review-and-meta
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www.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - Preliminary 2015 estimates indicate that more than 37,000 fewer patients died in hospitals in 2015 as … HACs from 2010 to 2015 indicates that hospitals have made substantial progress in improving safety. … expanded its efforts in order to extend the success that hospitals have achieved to all health care … MPSMS (2015)
In-Hospital Patient Falls
220,000
6.7
Obstetric Adverse Events
PSI (2014 … hospitals
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psnet.ahrq.gov/issue/6-year-thematic-review-reported-incidents-associated-cardiopulmonary-resuscitation-calls
June 15, 2022 - review of root cause analyses of falls leading to adverse events. … delays to identification of serious injury after falls in hospital inpatients. … 5 teaching hospitals. … in a Canadian regional hospital system: a retrospective time series analysis. … February 23, 2022
Medication safety in mental health hospitals: a mixed-methods analysis
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psnet.ahrq.gov/node/851658/psn-pdf
July 26, 2023 - The spectrum of hospitalization-associated harm in the
elderly.
July 26, 2023
Schattner A. … The spectrum of hospitalization-associated harm in the elderly. … older adults, including unnecessary testing or
procedures, nosocomial infections, medical errors, falls … patient-safety-frail-older-patients
https://psnet.ahrq.gov/issue/assessment-overuse-medical-tests-and-treatments-us-hospitals-using-medicare-claims … https://psnet.ahrq.gov/primer/falls
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - hospitals. … MPSMS In-Hospital Patient Falls
Obstetric
Adverse
Events
PSI OB Trauma in Vaginal Delivery
(PSI … MPSMS In-Hospital
Patient Falls
239,286 8.04 225,199 7.57 223,106 7.50 226,642 7.62
Obstetric … 4, 2015, hospitals began using ICD-10 coded data in place of ICD-9 coded data. … Conditions 23
The MPSMS-abstracted sample is representative of hospitals submitting cases to the Hospital
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psnet.ahrq.gov/issue/patient-safety-perception-within-hospitals-examination-job-type-handoffs-and-information
December 18, 2014 - and information exchange, and hospital management support. … , and hospital management support. … , and hospital management support. … August 19, 2020
Using human factors and ergonomics principles to prevent inpatient falls … May 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/issue/beyond-error-qualitative-study-human-factors-serious-adverse-events
December 18, 2024 - Root cause analysis investigation reports from two hospital districts were analyzed. … with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
December 18, 2024 … 27, 2024
Patient Safety Innovations
Preventing Falls … Dangerous Detour
June 1, 2003
View More
See More About The Topic
Hospitals … Hospital Medicine
Error Analysis
Communication between Providers
Provider-Patient Communication
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - hospital and ambulatory care
settings. … SNFs as in hospitals. … A WebM&M commentary highlights falls that occur in SNF
patients in more detail and gives evidence-based … Unfortunately, safety culture
in many long-term care facilities is poorer than that found in hospitals … These
require SNFs to have measures in place to prevent specific clinical harms (such as falls, pressure
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digital.ahrq.gov/program-overview/research-stories/clinical-decision-support-tool-preventing-falls
January 01, 2023 - Falls can have devastating health consequences for older adults but are not often discussed in primary … care
More than one in four older adults report falls each year, a common occurrence and the leading … Fall prevention is possible, but older adults who are at the highest risk of falling need to receive … Dykes and her team at Brigham and Women’s Hospital and collaborators at University of Florida and UCLA … Patricia
Organization Brigham and Women's Hospital Research Profile
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psnet.ahrq.gov/issue/framework-analysis-communication-errors-health-care
October 21, 2020 - Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to … clinical pharmacist-led transitions of care program for veterans with two planned care transitions (hospital … 14, 2023
Patient Safety Innovations
Preventing Falls … June 15, 2016
Partnering to prevent falls: using a multimodal multidisciplinary team. … Another Fall
April 1, 2003
View More
See More About The Topic
Hospitals
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psnet.ahrq.gov/issue/sustaining-gains-7-year-follow-through-hospital-wide-patient-safety-improvement-project
October 19, 2022 - hospital-wide adverse events at a single large hospital in Singapore. … December 8, 2021
Relationship between call light use and response time and inpatient falls … January 4, 2010
Innovation in patient safety: a new task design in reducing patient falls … October 21, 2010
How event reporting by US hospitals has changed from 2005 to 2009. … four UK hospitals: mixed method evaluation.
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digital.ahrq.gov/sites/default/files/docs/citation/r03hs027006-sun-final-report-2023.pdf
January 01, 2023 - in hospitals each year which, on average, cost hospitals an additional $17,483 per fall.3, 4
Increased … A hospital system approach at decreasing falls with injuries and cost. … Preventing Falls in Hospitals. … The scope of hospital falls: A systematic mixed studies review. … Preventing Falls in Hospitals: 5. How do
you measure fall rates and fall prevention practices?
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psnet.ahrq.gov/node/837430/psn-pdf
June 15, 2022 - /issue/stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission
Bedrails are used in … hospitals and at home to minimize falls despite the potential to contribute to patient
harm. … stop-using-these-adult-bed-rails-warns-consumer-product-safety-commission
https://psnet.ahrq.gov/issue/fda-guidance-document-hospital-bed-system-dimensional-and-assessment-guidance-reduce … do-split-side-rails-present-increased-risk-patient-safety
https://psnet.ahrq.gov/issue/effect-bedrails-falls-and-injury-systematic-review-clinical-studies
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www.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
October 01, 2015 - MPSMS (2013) In-Hospital Patient
Falls
240,000 7.2
Obstetric
Adverse
Events
PSI (2013) OB Trauma … A multicenter qualitative study on preventing hospital-acquired urinary tract
infection in U.S. hospitals … Reduction of falls-related injuries using a hospital inpatient falls
prevention program. … Characteristics and circumstances of falls in a hospital setting: a prospective
analysis. … Medicare nonpayment, hospital falls, and unintended consequences.
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www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
June 01, 2022 - Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care focuses on overcoming the challenges … The Guide to Patient and Family Engagement in Hospital Quality and Safety will help hospitals work … The Preventing Pressure Ulcers in Hospitals Toolkit assists hospital staff in implementing effective … represent a patient safety problem, and they can be a signal that the resident is at increased risk for falling … Three Addresses Falls Prevention and Management.
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psnet.ahrq.gov/issue/performance-trigger-tool-detecting-drug-related-hospital-admissions-older-people-analysis
December 21, 2022 - Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis … Triggers were related to diagnoses (e.g., falls, bleeding, thromboembolic events), laboratory values … Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis … mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) … hospital admissions in Multimorbid older people (OPERAM) trial.