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2961. Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies. | PSNet
      psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement
      January 18, 2013 - in conditions targeted by the Hospital Readmissions Reduction Program. … hospital practice: factors associated with turnover, outcomes, and patient safety. … March 18, 2020 Fall prevention in hospitals: an integrative review. … March 2, 2012 View More See More About The Topic Hospitals Quality … and Safety Professionals Hospital Medicine Nurse Care Failure to rescue View More

2962. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. | PSNet
      psnet.ahrq.gov/issue/structured-interdisciplinary-rounds-medical-teaching-unit-improving-patient-safety
      November 26, 2014 - The accompanying editorial notes that the hospital where this study was conducted had several structural … electronic health record), and that structured interdisciplinary rounds could have an even larger impact at hospitals … October 26, 2011 An inpatient fall prevention initiative in a tertiary care hospital. … August 18, 2010 Patient whiteboards as a communication tool in the hospital setting: … May 5, 2010 View More See More About The Topic Specialty Hospitals

2963. Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene. | PSNet
      psnet.ahrq.gov/issue/using-human-factors-framework-assess-clinician-perceptions-and-barriers-high-reliability-hand
      December 02, 2020 - critical care units and hospital emergency services. … , ethnic, and payer groups for pediatric safety events in US hospitals. … conditions in pediatric hospitals. … February 6, 2019 Childrens' Hospitals' Solutions for Patient Safety. … March 22, 2006 View More See More About The Topic Children's Hospitals

2964. Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. | PSNet
      psnet.ahrq.gov/issue/effectiveness-and-cost-transitional-care-program-heart-failure-prospective-study-concurrent
      April 24, 2019 - This study found that adoption of a nurse-led transitional care program produced a 48% reduction in … Related Resources From the Same Author(s) Differential safety between top-ranked cancer hospitals … August 17, 2018 Association between hospital penalty status under the Hospital Readmission … February 14, 2017 Patient and family engagement: a survey of US hospital practices. … hospitals: a focus group study.

2965. The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication administration process on the floor. | PSNet
      psnet.ahrq.gov/issue/amelie-project-failure-mode-effects-and-criticality-analysis-model-evaluate-nurse-medication
      September 24, 2016 - a teaching hospital. … for Sick Children in Toronto. … October 2, 2013 Parent perceptions of children's hospital safety climate. … children's hospitals. … April 11, 2011 View More See More About The Topic Children's Hospitals

2966. Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study. | PSNet
      psnet.ahrq.gov/issue/prescription-and-transcription-errors-multidose-dispensed-medications-discharge-hospital
      February 15, 2011 - Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: … Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: … discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective … June 1, 2012 The effect of medication reconciliation in elderly patients at hospital … February 4, 2009 View More See More About The Topic Hospitals Health

2967. Association of rapid response teams with hospital mortality in Medicare patients. | PSNet
      psnet.ahrq.gov/issue/association-rapid-response-teams-hospital-mortality-medicare-patients
      September 23, 2020 - Association of rapid response teams with hospital mortality in Medicare patients. … Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in … Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected … survival after in-hospital cardiac arrests. … July 7, 2021 Fall prevention implementation strategies in use at 60 United States hospitals

2968. A perinatal care quality and safety initiative: are there financial rewards for improved quality? | PSNet
      psnet.ahrq.gov/issue/perinatal-care-quality-and-safety-initiative-are-there-financial-rewards-improved-quality
      April 27, 2019 - An inconvenient truth about the patient safety movement is that in many cases hospitals actually profit … This study examined the financial impact of an effort to eliminate obstetric complications in a five-hospital … The project led to an 11% reduction in preventable adverse events, but hospital reimbursements decreased … a community hospital. … The effect of a tiered hospital network on hospital admissions.

2969. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
      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

2970. Premature Closure: Was It Just Syncope? | PSNet
      psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
      February 10, 2021 - the preceding months all resulting in falls and head trauma. … as ROWS, or “Rule Out Worst Case Scenario), or simply the one for which it is easiest to justify the hospital … Chart review or additional history-taking may have revealed the patient’s recent history of falls with … Approach to Improving Safety and Systems Change Needed To help clinicians avoid similar errors, hospitals … One example, currently in use at our hospital, requires providers ordering an MRI study to complete a

2971. Differential safety between top-ranked cancer hospitals and their affiliates for complex cancer surgery. | PSNet
      psnet.ahrq.gov/issue/differential-safety-between-top-ranked-cancer-hospitals-and-their-affiliates-complex-cancer
      July 24, 2019 - mortality and that the top-ranked hospital was safer than its affiliates in 84% of the networks in the … top-ranked cancer hospital. … February 15, 2012 An inpatient fall prevention initiative in a tertiary care hospital … August 10, 2011 Hospital costs associated with adverse events in gynecological oncology … February 3, 2010 Teamwork in the operating room: frontline perspectives among hospitals

2972. AHRQ's Guide to Evaluating Health Information Exchange Projects - Section 4 (pdf file)
      digital.ahrq.gov/sites/default/files/docs/page/guide-to-evaluating-hie-projects-section-4.pdf
      June 16, 2021 - An IRB and its representatives may be helpful in determining whether your project falls into either … They might retrieve hospital admission data for patients seen in the emergency department, for hospitals … : z Clinicians z Laboratory services z Pharmacies z Hospitals z Payers z Intermediaries … Measures falling into this box receive an overall rank or analysis value of 1. … Measures falling into this box receive an overall rank or quadrant analysis value of 5.

2973. PowerPoint Presentation
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medicinelist-slides-final508.pptx
      June 02, 2025 - the hospital or emergency room AND/OR Take 5 or more medicines AND/OR Have a chronic condition. 5 … with the list in the EHR. … He did have a few falls from his bike and has started using a stationary bike instead. … angioplasty Discharged from hospital 4 days ago Unremarkable medical history prior to MI EHR lists: … Santiago was discharged from the hospital 4 days ago after a myocardial infarction and the placement

2974. Disclosure of hospital adverse events and its association with patients' ratings of the quality of care. | PSNet
      psnet.ahrq.gov/issue/disclosure-hospital-adverse-events-and-its-association-patients-ratings-quality-care
      December 29, 2014 - An invited commentary [see link below] by a leader in the patient safety field, Dr. … review: do patients know something that hospitals do not? … January 18, 2017 The effect of hospital-acquired Clostridium difficile infection on in-hospital … April 5, 2013 Fall prevention in acute care hospitals: a randomized trial. … March 5, 2010 View More See More About The Topic General Hospitals

2975. The association between patient-reported incidents in hospitals and estimated rates of patient harm. | PSNet
      psnet.ahrq.gov/issue/association-between-patient-reported-incidents-hospitals-and-estimated-rates-patient-harm
      August 13, 2013 - Study The association between patient-reported incidents in hospitals and estimated … The association between patient-reported incidents in hospitals and estimated rates of patient harm. … The association between patient-reported incidents in hospitals and estimated rates of patient harm. … August 13, 2013 A comprehensive overview of medical error in hospitals using incident-reporting … March 14, 2012 Adverse events in hospitals: the patient's point of view.

2976. Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis. | PSNet
      psnet.ahrq.gov/issue/incidence-never-events-among-weekend-admissions-versus-weekday-admissions-us-hospitals
      November 03, 2015 - Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals … Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national … Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national … November 3, 2015 Survival from in-hospital cardiac arrest during nights and weekends. … October 16, 2012 Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries

2977. Hospital implementation of computerized provider order entry systems: results from the 2003 Leapfrog Group quality and safety survey. | PSNet
      psnet.ahrq.gov/issue/hospital-implementation-computerized-provider-order-entry-systems-results-2003-leapfrog-group
      November 21, 2021 - Study Hospital implementation of computerized provider order entry systems: results … Hospital implementation of computerized provider order entry systems: results from the 2003 leapfrog … September 30, 2010 Fall prevention in hospitals: an integrative review. … reported by U.S. hospitals in 2005 and 2009. … 5 community hospitals: a qualitative study.

2978. Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. | PSNet
      psnet.ahrq.gov/issue/validity-agency-healthcare-research-and-quality-patient-safety-indicators-and-centers
      June 14, 2017 - October 9, 2024 Medication errors associated with code situations in U.S. hospitals: … payor mix on patient safety indicators, October 7, 2020 Changes in hospital safety … following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study … July 24, 2019 HealthGrades Sixth Annual Patient Safety in American Hospitals Study. … March 13, 2013 HealthGrades Eighth Annual Patient Safety in American Hospitals Study.

2979. Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. | PSNet
      psnet.ahrq.gov/issue/differences-hospitals-workplace-violence-incident-reporting-practices-mixed-methods-study
      January 19, 2022 - Study Differences in hospitals' workplace violence incident reporting practices: … Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. … Differences in hospitals' workplace violence incident reporting practices: a mixed methods study. … hospital assessment units in England and Wales: a mixed methods analysis for quality improvement. … November 25, 2020 Barcode medication administration technology use in hospital practice

2980. Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals. | PSNet
      psnet.ahrq.gov/issue/medication-safety-events-after-acute-myocardial-infarction-among-veterans-treated-va-versus
      April 07, 2022 - Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals … examined the use of outpatient medications for secondary prevention (e.g., beta blockers, statins) in … The researchers found that medication omissions, duplications and delays in prescribing of secondary … prevention medications were more common among patients treated at non-VA hospitals. … a multistate hospital network--13 academic medical centers, April-June 2020.