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3161. Final Progress Report: Evaluate the Effects of the Massachusetts Reporting System (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/ridley-report.pdf
      January 01, 2024 - Aim 3: Hospital leaders think mandatory reporting discourages adverse event reporting in their hospitals … Adjustments to the sample included under-sampling reported falls to insure inclusion of all rarer types … A larger percentage of these incidents were falls involving fracture, but not death of the patient, … The hospitals were selected from hospital association lists or from the AHA Guide to Hospitals 2001- … hospital status (five hospitals - pediatrics, cancer, eye and ear, hospice), closure (two hospitals

3162. Second Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/annlrpt2012%20(2).pdf
      November 01, 2012 - in community- Dwelling Older adults falls in community-dwelling adults aged 65 years or older who are … at increased risk for falls. … Reyes is a practicing perinatologist in maternal and fetal medicine at Virginia Hospital Center in Arlington … risk for Falls The USPSTF recommends exercise or physical therapy to prevent falls in community-dwelling … risk for Falls The USPSTF recommends vitamin D supplementation to prevent falls in community-dwelling

3163. Blood Thinner Pills: Your Guide to Using Them Safely | Agency for Healthcare Research and Quality
      www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/btpills.html
      March 01, 2023 - This guide is also available in Spanish [   PDF - 3.MB] .   … Mark the missed dose in a diary or on a calendar. … Return to Contents   Stay Safe While Taking Your Blood Thinner Call your doctor and go to the hospital … If you like to work in the yard, you still can. … Testing your blood helps your doctor keep you in a safe range.

3164. Incidence of nosocomial COVID-19 in patients hospitalized at a large US academic medical center. | PSNet
      psnet.ahrq.gov/issue/incidence-nosocomial-covid-19-patients-hospitalized-large-us-academic-medical-center
      October 14, 2020 - returns to hospital: a randomized clinical trial. … validation of a deep learning model for detection of allergic reactions using safety event reports across hospitals … October 5, 2022 Assessment of overuse of medical tests and treatments at US hospitals … SARS-CoV-2 in hospital settings in the UK: a cohort study. … May 13, 2020 View More See More About The Topic Hospitals Health Care

3165. Implementation, Adoption, and Scaling Workgroup: Exploring Challenges and Opportunities for Patient Engagement, Implementation, Adoption, and Scaling Through PC CDS Case Studies (pdf file)
      cdsic.ahrq.gov/sites/default/files/2024-09/Final%20IAS%20PC%20CDS%20Case%20Studies%20Report_2.pdf
      January 01, 2024 - Assessing electronic health literacy at an urban academic hospital. … Health Issue: Older adults, who are at highest risk for falls, need to receive appropriate interventions … However, clinicians do not routinely ask at-risk patients about falls or their associated risk factors … Brigham and Women’s Hospital. Final Report. 2022. … Brigham and Women’s Hospital. Final Report. 2022.

3166. Administration of concentrated potassium chloride for injection during a code: still deadly! | PSNet
      psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-deadly
      May 02, 2018 - June 10, 2018 Selected medication safety risks to manage in 2016 that might otherwise … February 1, 2023 Medication errors: the year in review: January through December 2021 … Administration Blur June 24, 2020 View More See More About The Topic Hospitals … Intensive Care Units Health Care Executives and Administrators Quality and Safety Professionals Hospital

3167. Stepping out further from the shadows: disclosure of harmful radiologic errors to patients. | PSNet
      psnet.ahrq.gov/issue/stepping-out-further-shadows-disclosure-harmful-radiologic-errors-patients
      April 21, 2011 - April 21, 2011 Seroprevalence of SARS-CoV-2 among frontline health care personnel in … a multistate hospital network--13 academic medical centers, April-June 2020. … August 4, 2021 Patient concerns about medical errors in emergency departments. … September 25, 2019 In support of the medical apology: the nonlegal arguments. … November 18, 2016 Reflection on adverse event disclosure in the postsurgical hospital

3168. Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility. | PSNet
      psnet.ahrq.gov/issue/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility
      July 27, 2016 - Magazine Article Paralyzed by mistakes: reassess the safety of neuromuscular blockers in … Citation Text: Paralyzed by mistakes: reassess the safety of neuromuscular blockers in your facility … Neuromuscular blockers can result in serious harm if administered incorrectly. … June 19, 2019 Accidental IV infusion of heparinized irrigation in the OR. … February 27, 2009 View More See More About The Topic Hospitals Physicians

3169. Emergency lights and sirens on ambulances may do more harm than good. | PSNet
      psnet.ahrq.gov/issue/emergency-lights-and-sirens-ambulances-may-do-more-harm-good
      February 15, 2023 - June 17, 2020 Raising an alarm, doctors fight to yank hospital ICUs into the modern era … August 2, 2023 The next generation of doctors may be learning bad habits at teaching hospitals … September 6, 2023 The effect of documenting patient weight in kilograms on pediatric … medication dosing errors in emergency medical services. … May 3, 2023 NHS staff cried in safety interviews, says watchdog.

3170. Staff warned about the lack of psychiatric care at a VA clinic. They couldn’t prevent tragedy. | PSNet
      psnet.ahrq.gov/issue/staff-warned-about-lack-psychiatric-care-va-clinic-they-couldnt-prevent-tragedy
      December 12, 2018 - rural community culminated in criminal harm, incarceration, and delayed healing. … September 22, 2021 The last person you'd expect to die in childbirth. … VA Medical Center in Memphis, Tennessee. … January 31, 2024 The Sunday story: when hospitals don't say sorry. … January 24, 2024 Investigators find hospital error caused mother’s death in Brooklyn.

3171. Network of Patient Safety Databases Chartbook. | PSNet
      psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook
      October 23, 2019 - Resources From the Same Author(s) AHRQ Health Information Technology Research: 2018 Year in … January 14, 2024 Burnout in Primary Care: Assessing and Addressing It in Your Practice … December 24, 2008 Improving Medication Safety in High Risk Medicare Beneficiaries Toolkit … October 6, 2021 Making Health Care Safer in Ambulatory Care Settings and Long-term Care … August 19, 2020 View More See More About The Topic Researchers Hospitals

3172. Recognizing the importance of whistleblowers in healthcare. | PSNet
      psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
      June 24, 2009 - Recognizing the importance of whistleblowers in healthcare. … Recognizing the importance of whistleblowers in healthcare. … care hospital units. … in undergraduate nursing students: a systematic review. … June 23, 2009 View More Related Resources Hospitals in two states

3173. ASPEN parenteral nutrition safety consensus recommendations: translation into practice. | PSNet
      psnet.ahrq.gov/issue/aspen-parenteral-nutrition-safety-consensus-recommendations-translation-practice
      February 17, 2015 - This commentary describes strategies to promote the use of parenteral nutrition safety guidelines in … August 4, 2021 Addressing disease-related malnutrition in hospitalized patients: a call … , 2014 Avoiding potential harm by improving appropriateness of urinary catheter use in … February 28, 2011 Creating high reliability in health care organizations. … January 20, 2010 View More See More About The Topic Hospitals Physicians

3174. Dangerous deception--hiding the evidence of adverse drug events. | PSNet
      psnet.ahrq.gov/issue/dangerous-deception-hiding-evidence-adverse-drug-events
      November 09, 2022 - International variations in the safety information accompanying top-selling prescription drugs. … March 2, 2011 Medication-attributed adverse effects in placebo groups: implications for … Massachusetts Hospitals. … Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in … August 10, 2010 Iatrogenic disease management: moderating medication errors and risks in

3175. Ambiguities of chronic illness management and challenges to the medical error paradigm. | PSNet
      psnet.ahrq.gov/issue/ambiguities-chronic-illness-management-and-challenges-medical-error-paradigm
      July 02, 2014 - July 2, 2014 Nurse Staffing Levels, Missed Vital Signs and Mortality in Hospitals: Retrospective … in outpatient settings: clinical practice guideline. … July 29, 2020 Cognitive error in an academic emergency department. … February 22, 2012 Addressing safety concerns about U-500 insulin in a hospital setting … June 11, 2010 Finding blunders in thyroid testing: experience in newborns.

3176. Effectiveness of a computerized system for intravenous heparin administration: using information technology to improve patient care and patient safety. | PSNet
      psnet.ahrq.gov/issue/effectiveness-computerized-system-intravenous-heparin-administration-using-information
      February 27, 2009 - They found significant improvements in the safety of this drug's administration. … RIS Download Citation Related Resources From the Same Author(s) Hospital … March 24, 2019 Differences in day and night shift clinical performance in anesthesiology … June 14, 2011 Optimizing Pediatric Patient Safety in the Emergency Care Setting. … October 19, 2022 Prevalence and causes of diagnostic errors in hospitalized patients

3177. Applying the Toyota Production System: using a patient safety alert system to reduce error. | PSNet
      psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
      June 21, 2015 - The authors describe their institution's Patient Safety Alert system in which employees are required  … May 7, 2014 Fatigue and safety in paramedicine. … December 18, 2019 Adverse respiratory events in anesthesia: a closed claims analysis. … Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital … Wristband July 1, 2003 View More See More About The Topic Hospitals

3178. Patient safety and acute care medicine: lessons for the future, insights from the past. | PSNet
      psnet.ahrq.gov/issue/patient-safety-and-acute-care-medicine-lessons-future-insights-past
      April 27, 2022 - A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in … a United Kingdom hospital. … January 24, 2024 Seroprevalence of SARS-CoV-2 among frontline health care personnel in … a multistate hospital network--13 academic medical centers, April-June 2020. … March 3, 2011 Technology, governance and patient safety: systems issues in technology

3179. Major congenital malformations after first-trimester exposure to ACE inhibitors. | PSNet
      psnet.ahrq.gov/issue/major-congenital-malformations-after-first-trimester-exposure-ace-inhibitors
      July 10, 2008 - Related Resources From the Same Author(s) Prevention of fall-related injuries in … March 3, 2011 Prescription of long-acting opioids and mortality in patients with chronic … January 23, 2017 A multi-hospital before–after observational study using a point-prevalence … January 10, 2007 Fatal drug mix-up exposes hospital flaws.

3180. Error disclosure and apology in radiology: the case for further dialogue. | PSNet
      psnet.ahrq.gov/issue/error-disclosure-and-apology-radiology-case-further-dialogue
      October 19, 2022 - Error Disclosure and Apology in Radiology: The Case for Further Dialogue. … Error Disclosure and Apology in Radiology: The Case for Further Dialogue. … November 11, 2015 Key principles in quality and safety in radiology. … July 5, 2023 Hospital image repair strategies, organizational apology, and medical errors … January 18, 2017 View More See More About The Topic Hospitals Physicians