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2741. Do not let "Depo-" medications be a depot for mistakes. | PSNet
      psnet.ahrq.gov/issue/do-not-let-depo-medications-be-depot-mistakes
      March 15, 2022 - Related Resources From the Same Author(s) Survey suggests disrespectful behaviors persist in … March 15, 2022 Selected medication safety risks to manage in 2016 that might otherwise … August 28, 2019 Safety enhancements every hospital must consider in wake of another tragic … January 27, 2009 Fatal drug mix-up exposes hospital flaws. … September 27, 2006 View More See More About The Topic Hospitals Health

2742. Perianesthesia nursing advocacy: an influential voice for patient safety. | PSNet
      psnet.ahrq.gov/issue/perianesthesia-nursing-advocacy-influential-voice-patient-safety
      June 08, 2022 - hospitals. … March 2, 2011 Rapid response team in a rural hospital. … hospital practice: factors associated with turnover, outcomes, and patient safety. … May 3, 2017 Missed nursing care in pediatrics. … April 6, 2011 Nurse reports of adverse events during sedation procedures at a pediatric hospital

2743. ASHP guidelines on the safe use of automated dispensing devices. | PSNet
      psnet.ahrq.gov/issue/ashp-guidelines-safe-use-automated-dispensing-devices
      July 05, 2017 - July 29, 2020 Identifying risk in the use of tumor markers to improve patient safety. … a multistate hospital network--13 academic medical centers, April-June 2020. … View More Related Resources Targeted Medication Safety Best Practices for Hospitals … January 27, 2010 View More See More About The Topic Hospitals Health … Care Providers Quality and Safety Professionals Information Professionals Hospital Pharmacy

2744. Cognitive biases associated with medical decisions: a systematic review. | PSNet
      psnet.ahrq.gov/issue/cognitive-biases-associated-medical-decisions-systematic-review
      March 01, 2023 - Cognitive bias can contribute to diagnostic error , leading to delays in treatment and unnecessary … September 15, 2021 Community pharmacy medication review, death and re-admission after hospital … September 21, 2022 Honest communication and social asymmetries inside a hospital: pitfalls … July 3, 2016 "First, know thyself": cognition and error in medicine. … April 15, 2016 View More See More About The Topic Hospitals Facility

2745. Legislative Report to the General Assembly: Adverse Event Reporting. | PSNet
      psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting
      May 20, 2009 - May 20, 2009 Detection of missed fractures of hand and forearm in whole-body CT in a … September 29, 2021 Southern Baptist Hospital of Florida v. Charles. … September 28, 2022 Organizational safety climate and job enjoyment in hospital surgical … January 18, 2012 The High Costs of Weak Compliance With the New York State Hospital Adverse … April 26, 2006 View More See More About The Topic Hospitals Policy

2746. The impact of electronic medical records on hospital-acquired adverse safety events: differential effects between single-source and multiple-source systems. | PSNet
      psnet.ahrq.gov/issue/impact-electronic-medical-records-hospital-acquired-adverse-safety-events-differential
      October 24, 2012 - likely to have hospital-acquired safety events compared to hospitals with multiple systems in place. … a pediatric hospital system. … September 19, 2018 A national survey assessing the number of records allowed open in … electronic health records at hospitals and ambulatory sites. … February 10, 2018 Progress in interoperability: measuring US hospitals' engagement in

2747. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/painmgmt-facguide.docx
      January 01, 2017 - the ICU and within the hospital. … Slide 10 Keystone’s ABCDE Bundle Collaborative Results SAY: In this study of 51 hospitals involved … Keep in mind some of the things you can do to make the hospital environment less stressful, including … mortality in the ICU and the total percentage of mortality in the hospital after using the ABCDE bundle … infections, falls, deep vein thromboses, pressure ulcers, and medication errors.

2748. Evidence Behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Facilitator Guide | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-fac-guide.html
      January 01, 2017 - the ICU and within the hospital.  … Slide 11: Keystone’s ABCDE Bundle Collaborative Results Say: In this study of 51 hospitals involved … Keep in mind some of the things you can do to make the hospital environment less stressful, including … of mortality in the ICU and the total percentage of mortality in the hospital after using the ABCDE … infections, falls, deep vein thromboses, pressure ulcers, and medication errors. 

2749. Adverse events in hospitalized paediatric patients: a systematic review and a meta-regression analysis. | PSNet
      psnet.ahrq.gov/issue/adverse-events-hospitalized-paediatric-patients-systematic-review-and-meta-regression
      February 25, 2015 - Assessment of a wearable fall prevention system at a Veterans Health Administration hospital … July 10, 2024 Drug-drug interactions and prescription appropriateness at hospital discharge … February 27, 2014 Drug administration errors in hospital inpatients: a systematic review … March 18, 2011 View More See More About The Topic Children's Hospitals … Quality and Safety Professionals Safety Scientists Hospital Medicine Pediatrics

2750. If only...: failed, missed and absent error recovery opportunities in medication errors. | PSNet
      psnet.ahrq.gov/issue/if-only-failed-missed-and-absent-error-recovery-opportunities-medication-errors
      July 15, 2009 - hospitals. … April 5, 2013 Errors in medication history at hospital admission: prevalence and predicting … March 31, 2009 Characteristics of medication errors and adverse drug events in hospitals … November 12, 2008 View More See More About The Topic Hospitals Quality … and Safety Professionals General Internal Medicine Hospital Medicine Hospital Pharmacy

2751. A framework for patient safety: a defense nuclear industry-based high-reliability model. | PSNet
      psnet.ahrq.gov/issue/framework-patient-safety-defense-nuclear-industry-based-high-reliability-model
      June 14, 2017 - hospital practice: factors associated with turnover, outcomes, and patient safety. … US hospitals. … April 1, 2015 Evidence-based organization and patient safety strategies in European hospitals … June 30, 2011 The Patient Safety Initiative at America’s Public Hospitals: The Year One … February 9, 2011 View More See More About The Topic Hospitals Health

2752. Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative systematic review. | PSNet
      psnet.ahrq.gov/issue/medication-related-emergency-department-visits-and-hospital-admissions-pediatric-patients
      March 13, 2015 - Review Medication-related emergency department visits and hospital admissions in … Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative … Medication-related emergency department visits and hospital admissions in pediatric patients: a qualitative … and adverse events in older patients admitted to hospital: a retrospective cohort study. … and adverse events in older patients admitted to hospital: a retrospective cohort study.

2753. Use of specific indicators to detect warfarin-related adverse events.   | PSNet
      psnet.ahrq.gov/issue/use-specific-indicators-detect-warfarin-related-adverse-events
      October 19, 2022 - October 19, 2022 Families as partners in hospital error and adverse event surveillance … February 27, 2019 ASHP national survey of pharmacy practice in hospital settings: prescribing … September 20, 2017 ASHP national survey of pharmacy practice in hospital settings: monitoring … July 20, 2016 ASHP national survey of pharmacy practice in hospital settings: prescribing … May 29, 2014 Medication error reporting in rural critical access hospitals in the North

2754. Patient safety measures in burn care: do national reporting systems accurately reflect quality of burn care? | PSNet
      psnet.ahrq.gov/issue/patient-safety-measures-burn-care-do-national-reporting-systems-accurately-reflect-quality
      August 20, 2018 - a multistate hospital network--13 academic medical centers, April-June 2020. … hospital practice: factors associated with turnover, outcomes, and patient safety. … February 6, 2012 An inpatient fall prevention initiative in a tertiary care hospital. … a Canadian tertiary hospital. … September 9, 2009 View More See More About The Topic Specialty Hospitals

2755. Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. | PSNet
      psnet.ahrq.gov/issue/medication-errors-and-error-chains-involving-high-alert-medications-paediatric-hospital
      March 27, 2024 - Medication errors and error chains involving high-alert medications in a paediatric hospital setting: … This study determined that most self-reported high-alert medication errors in a children’s hospital … Medication errors and error chains involving high-alert medications in a paediatric hospital setting: … June 5, 2024 Systemic defenses to prevent intravenous medication errors in hospitals: … February 3, 2021 6-PACK programme to decrease fall injuries in acute hospitals: cluster

2756. Puh-Factraining-Guide (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docx
      June 02, 2025 - 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

2757. Building Capacity for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/building-capacity-patient-safety
      July 31, 2023 - After nursing school, I worked as a staff nurse in a hospital, then as a director of nursing in a long-term … That is the microsystem of the learning system in Pennsylvania and what is happening within each hospital … We advise hospitals through publication. … event and risk information back to health systems in order to impact hospital processes related to that … We were working not on falls or adverse drug reactions, but on the overarching issues that could make

2758. Leveraging Existing Assessments of Risk Now (LEARN) Safety Analysis: A Method for Extending Patient Safety Learning (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-woods_79.pdf
      May 30, 2008 - The categories are effective for designating medical care processes in both hospital-based and ambulatory … procedure has a formal built-in check and other safeguards S2 Formal check Hospital procedure includes … Amsden); National Association of Children’s Hospitals and Related Institutions (Dr. … Engineers study design, hospital cuts falls 50%. Healthcare Risk Manage 2006; 1 Aug. … Hospital reported medical errors in children. Pediatrics 2003; 111: 617-621. 10.

2759. Are evidence-based practices associated with effective prevention of hospital-acquired pressure ulcers in US academic medical centers? | PSNet
      psnet.ahrq.gov/issue/are-evidence-based-practices-associated-effective-prevention-hospital-acquired-pressure
      September 23, 2020 - Severe hospital-acquired pressure ulcers are considered a never event , and they result in loss of payment … the incidence of hospital-acquired pressure ulcers in academic medical centers. … January 23, 2019 Success in hospital-acquired pressure ulcer prevention: a tale in two … ulcers in a system of community hospitals. … March 7, 2018 Pressure Injury Prevention in Hospitals Training Program.

2760. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. | PSNet
      psnet.ahrq.gov/issue/unintended-discontinuation-medication-following-hospitalisation-retrospective-cohort-study
      September 05, 2018 - As with prior studies , medication documentation in hospital discharge summaries remains highly variable … in primary care and its association with hospital admission: longitudinal study. … discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective … August 26, 2020 Role of relatives of ethnic minority patients in patient safety in hospital … September 20, 2012 The effect of medication reconciliation in elderly patients at hospital