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2601. First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). | PSNet
      psnet.ahrq.gov/issue/first-annual-review-data-submitted-ismp-national-vaccine-errors-reporting-program-verp
      June 10, 2018 - July 3, 2013 Managing Patients' Medicines after Discharge from Hospital. … June 29, 2011 Frequency of and risk factors for preventable medication-related hospital … admissions in the Netherlands. … May 13, 2009 Medication errors in family practice, in hospitals and after discharge from … the hospital: an ethical analysis.

2602. Technology and error-prevention strategies: why are we still overlooking the IV room? | PSNet
      psnet.ahrq.gov/issue/technology-and-error-prevention-strategies-why-are-we-still-overlooking-iv-room
      July 08, 2015 - February 1, 2023 Selected medication safety risks to manage in 2016 that might otherwise … June 16, 2019 ASHP guidelines on preventing medication errors in hospitals. … June 10, 2018 Paralyzed by mistakes: reassess the safety of neuromuscular blockers in … April 12, 2006 View More See More About The Topic Hospitals Pharmacists … Hospital Medicine Hospital Pharmacy Medication Errors/Preventable Adverse Drug Events

2603. How chaos at chain pharmacies is putting patients at risk. | PSNet
      psnet.ahrq.gov/issue/how-chaos-chain-pharmacies-putting-patients-risk
      June 12, 2019 - Pharmacists are instrumental to safe medication use in the ambulatory setting. … May 16, 2018 Reducing preventable harm in hospitals. … February 12, 2016 Investigators find hospital error caused mother’s death in Brooklyn … January 24, 2024 A night in the hospital, from both ends of the stethoscope. … September 20, 2023 Hospitals in two states denied an abortion to a miscarrying patient

2604. Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers. | PSNet
      psnet.ahrq.gov/issue/bleeding-and-pain-pregnant-woman-louisiana-couldnt-get-answers
      January 18, 2023 - Citation Text: Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers. … January 18, 2023 Preeminent hospitals penalized over rates of patients’ injuries. … February 19, 2020 Half of hospitals in Conn., Del. hit by Medicare's safety penalties … Rural hospitals weigh keeping obstetric units when births decline. … June 7, 2023 Hospitals in two states denied an abortion to a miscarrying patient.

2605. Beyond the Quick Fix: Strategies for Improving Patient Safety. | PSNet
      psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety
      March 14, 2018 - February 8, 2017 Never Events for Hospital Care in Canada: Safer Care for Patients. … Patient Safety in Canada. … November 30, 2016 Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 … November 25, 2015 Never Events for Hospital Care in Canada: Safer Care for Patients. … September 23, 2015 View More See More About The Topic Hospitals Health

2606. Challenge Competition: Impact of Patient Safety Tools. | PSNet
      psnet.ahrq.gov/issue/challenge-competition-impact-patient-safety-tools
      December 24, 2008 - hospitals , emergency departments, long-term care facilities, and ambulatory settings to prevent … December 24, 2008 AHRQ Health Information Technology Research: 2018 Year in Review. … May 1, 2017 Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs. … February 15, 2023 A scoping review of adverse incidents research in aged care homes: … August 26, 2020 View More See More About The Topic Researchers Hospitals

2607. Adverse Health Events in Minnesota: Annual Reports. | PSNet
      psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report
      February 28, 2015 - Since 2003, Minnesota hospitals have been required to report such incidents. … March 14, 2022 Quantifying discharge medication reconciliation errors at 2 pediatric hospitals … January 16, 2025 Your Safety in our Hands in Hospital. … DeBakey VA Medical Center in Houston, Texas. … View More See More About The Topic Outpatient Surgery Psychiatric Facilities Hospitals

2608. State sepsis mandates—a new era for regulation of hospital quality. | PSNet
      psnet.ahrq.gov/issue/state-sepsis-mandates-new-era-regulation-hospital-quality
      October 02, 2019 - State Sepsis Mandates - A New Era for Regulation of Hospital Quality. … State Sepsis Mandates - A New Era for Regulation of Hospital Quality. … safety-net hospitals: an analysis of Medicare's SEP-1 performance measure. … May 5, 2021 Delayed time to defibrillation after in-hospital cardiac arrest. … May 20, 2020 View More See More About The Topic Hospitals Facility

2609. Hospital nurses' work environment characteristics and patient safety outcomes: a literature review. | PSNet
      psnet.ahrq.gov/issue/hospital-nurses-work-environment-characteristics-and-patient-safety-outcomes-literature
      October 24, 2018 - acute-care hospitals. … October 27, 2021 Organizational learning in hospitals: a realist review. … August 20, 2018 Realist synthesis of intentional rounding in hospital wards: exploring … April 27, 2016 Fall prevention in hospitals: an integrative review. … March 2, 2012 View More See More About The Topic Hospitals Nurses

2610. The human factor. To improve patients safety, hospitals urged to adjust for how staff use new technology. | PSNet
      psnet.ahrq.gov/issue/human-factor-improve-patients-safety-hospitals-urged-adjust-how-staff-use-new-technology
      April 22, 2016 - Nurses' perception of medication administration errors and factors associated with their reporting in … January 17, 2024 Prevalence, causes and severity of medication administration errors in … December 14, 2022 Miscoding, misclassification and misdiagnosis of diabetes in primary … February 22, 2012 A proposed approach to allegations of sexual boundary violation in … November 1, 2012 Computer viruses are "rampant" on medical devices in hospitals.

2611. Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure." | PSNet
      psnet.ahrq.gov/issue/hospitalization-associated-disability-she-was-probably-able-ambulate-im-not-sure
      August 04, 2015 - This commentary reviews the epidemiology of hospital-associated disability—the long-term loss of ability … Download Citation Related Resources From the Same Author(s) Support from hospital … UK hospitals. … November 4, 2015 Detection of adverse events in an acute geriatric hospital over a 6- … February 11, 2009 View More See More About The Topic Specialty Hospitals

2612. Nurse practitioner–led medication reconciliation in critical access hospitals. | PSNet
      psnet.ahrq.gov/issue/nurse-practitioner-led-medication-reconciliation-critical-access-hospitals
      March 18, 2020 - Study Nurse practitioner–led medication reconciliation in critical access hospitals … Nurse Practitioner–led Medication Reconciliation in Critical Access Hospitals. … Nurse Practitioner–led Medication Reconciliation in Critical Access Hospitals. … March 29, 2023 Predictive combinations of monitor alarms preceding in-hospital code blue … August 22, 2012 Patients taking their own medications while in the hospital.

2613. Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? | PSNet
      psnet.ahrq.gov/issue/learning-mistakes-new-zealand-hospitals-what-else-do-we-need-besides-no-fault
      March 16, 2022 - Study Learning from mistakes in New Zealand hospitals: what else do we need besides … Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? … Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? … March 16, 2022 Hospital-readmission risk--isolating hospital effects from patient effects … May 24, 2010 View More See More About The Topic Hospitals Facility

2614. Halpern, Scott | Agency for Healthcare Research and Quality
      www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumhalp.html
      October 01, 2014 - Halpern is an Assistant Professor in the Center for Clinical Epidemiology and Biostatistics at the University … He received both his MD and PhD in Epidemiology from the University of Pennsylvania. … Progress to Date: The required patient- and unit-level data at the Hospital of the University of Pennsylvania … : Data collection will continue through the summer and fall and the clinician interview will begin in … Greenwall Foundation Faculty Scholar Award in Bioethics, 2008.

2615. Teamworknotes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/implement/teamworknotes.docx
      June 02, 2025 - are reported 75 percent of the time and represent the vast majority of repairable defects within the hospital … The message sender calls out information about the patient (for example, by saying, “BP is falling, 80 … acknowledges receipt of this message by confirming the information (for example, by saying, “Yes, the BP is falling … safety concerns—Provide critical lab values or reports, socioeconomic factors, allergies, and alerts (falls … about culture within the hospital.

2616. Facilitator-Notes (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module4/facilitator-notes.docx
      March 01, 2017 - When a patient is being transferred from the hospital to a nursing home or during a change of shift report … For example, they might discuss the resident’s decreasing mobility and the risk for falls. … The team could then make a plan to keep the resident from falling by providing a walker and teaching … Let’s say a resident becomes acutely ill and needs one-on-one care in preparation for transfer to a hospital … , response to treatment S Safety Concerns—Provide critical lab values/reports, allergies, alerts (falls

2617. Sustaining Zero CLABSIs (Transcript) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cusp/toolkit/content-calls/zero-clabsi.html
      April 01, 2013 - And part of the reason was that we saw more non-ICU units coming in was that our hospitals in the second … in their hospitals where a central line infection was still occurring. … In looking at what they saw in the technical difference, we noticed that for some hospitals it was very … And I think from our findings there as we work with hospitals within the Hospital Engagement Network, … line infections, urinary catheter infections, ventilator-associated infections, obstetric disasters, falls

2618. Presentation: Program Overview
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/build-businesscase-slides.pptx
      January 01, 2017 - Healthcare-Acquired Conditions (HACs) Series 1 VAPs SSIs CLABSI Other HACs Pressure Ulcers Post-op DVTs Falls … VACs -65% in IVACs* SAT and SBT Increases +63% in SATs +16% in SBTs +81% in SBTs done with sedatives … CFO is— A consultant to hospital leadership The gatekeeper of hospital assets Focused on the bottom … length of stay in intensive care unit and/or hospital through specific interventions Collect local data … 21,000 CLABSI $ 17,000 Other HACs $ 17,000 Pressure Ulcers $ 17,000 Post-op DVTs $ 8,000 Falls

2619. Reducing medication errors for adults in hospital settings. | PSNet
      psnet.ahrq.gov/issue/reducing-medication-errors-adults-hospital-settings
      March 09, 2022 - Review Reducing medication errors for adults in hospital settings. … Reducing medication errors for adults in hospital settings. … Reducing medication errors for adults in hospital settings. … June 16, 2021 Medication-related interventions delivered both in hospital and following … August 24, 2011 View More See More About The Topic Researchers Hospitals

2620. Incidence and method of suicide in hospitals in the United States. | PSNet
      psnet.ahrq.gov/issue/incidence-and-method-suicide-hospitals-united-states
      October 04, 2023 - Study Incidence and method of suicide in hospitals in the United States. … Incidence and Method of Suicide in Hospitals in the United States. … Incidence and Method of Suicide in Hospitals in the United States. … June 7, 2023 Infection control measure performance in long-term care hospitals and their … March 6, 2019 Medication safety in a psychiatric hospital.