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psnet.ahrq.gov/node/41298/psn-pdf
November 27, 2012 - Patient safety culture and the association with safe
resident care in nursing homes. … Patient safety culture and the association with safe resident care in
nursing homes. … a structure (safety culture), a process (use of physical restraints), and an
outcome (incidence of falls … statistically significant association between higher
safety culture scores, lower use of restraints, and fewer falls … https://psnet.ahrq.gov/primer/culture-safety
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
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psnet.ahrq.gov/issue/staffing-teamwork-and-scope-practice-analysis-association-patient-safety-context
September 20, 2017 - July 11, 2018
ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical … October 28, 2020
ASHP national survey of pharmacy practice in hospital settings: prescribing … June 5, 2019
Influence of unit-level staffing on medication errors and falls in military … hospitals. … care hospital units.
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www.ahrq.gov/sites/default/files/2024-11/gershon-report.pdf
January 01, 2024 - some ways, much more complicated in HHC compared to hospitals. … healthcare workers in hospitals and have
far less co-worker support. … and the rate of falls and fatalities due to falls, in the community
and in institutions, is greatest … the home and the rate of falls
and fatalities due to falls, in the community and in institutions, is … A National Profile of Patient
Safety In U.S. Hospitals. Health Affairs. 2003;22(2):154-166.
22.
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psnet.ahrq.gov/issue/measured-response-identified-suicide-risk-and-violence-what-you-need-know-about-psychiatric
January 30, 2019 - April 12, 2023
Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency … May 11, 2016
Provider-patient communication and hospital ratings: perceived gaps and … December 16, 2020
Safety events in children's hospitals during the COVID-19 pandemic. … March 18, 2015
Reducing falls and fall-related injuries in mental health: a 1-year multihospital … falls collaborative.
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psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis
August 04, 2021 - mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … September 7, 2022
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … and Quality of Long Term Care
September 1, 2011
Utilization of the Seniors Falls … Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.
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psnet.ahrq.gov/issue/fable-reality-parkland-hospital-impact-evidence-based-design-strategies-patient-safety
September 09, 2020 - In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable … to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls … a VA hospital: design and outcomes. … May 31, 2023
Patient Safety Innovations
Preventing Falls … February 8, 2012
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General Hospitals
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digital.ahrq.gov/ahrq-funded-projects/shareable-interoperable-clinical-decision-support-older-adults-advancing-fall
January 01, 2023 - Fall prevention is possible, but older adults who are at the highest risk of falling need to receive … to prevent falls is challenging. … (Prepared by Brigham and Women's Hospital under Grant No. U18 HS027557). … 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
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psnet.ahrq.gov/issue/field-guide-collaborative-care-implementing-future-health-care
March 09, 2018 - Resources
Perspective
The Ongoing Journey to Prevent Patient Falls … with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
December 18, 2024 … October 19, 2016
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help … October 5, 2011
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Hospitals
Health … Care Providers
Health Care Executives and Administrators
Patients
Hospital Medicine
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psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
January 13, 2021 - Citation Text:
Cost of medication-related problems at a university hospital. … older adults with a history of falls: a qualitative study. … review of root cause analyses of falls leading to adverse events. … January 30, 2019
Adverse drug events and medication problems in "Hospital at Home" patients … April 27, 2010
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Hospitals
Health
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psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis
June 21, 2017 - The most common incidents were falls and delayed response to clinical deterioration. … November 21, 2012
Root cause analysis of reported patient falls in ORs in the Veterans … March 25, 2020
Suicide and suicide attempts on hospital grounds and clinic areas. … December 4, 2016
Inpatient suicide and suicide attempts in Veterans Affairs hospitals … January 18, 2011
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Hospitals
Allied
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psnet.ahrq.gov/issue/nursing-practice-hospitalised-older-people-safety-and-harm
April 24, 2018 - This review found that restraint use and limiting mobility to prevent falls can result in functional … hospital error and adverse event surveillance. … December 8, 2021
Do falls and other safety issues occur more often during handovers when … August 7, 2019
Fall prevention in hospitals: an integrative review. … July 8, 2009
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Hospitals
Nurses
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psnet.ahrq.gov/issue/lehigh-valley-hospital-engaging-patients-and-families
January 04, 2017 - Lehigh Valley Hospital: engaging patients and families. … Lehigh Valley Hospital: engaging patients and families. … Resources
Perspective
The Ongoing Journey to Prevent Patient Falls … with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
December 18, 2024 … Patient Safety
March 1, 2007
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See More About The Topic
Hospitals
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www.ahrq.gov/hai/pfp/haccost2017-ref.html
May 01, 2023 - Serious falls in hospitalized patients: correlates and resource utilization. … The economics of preventing hospital falls: demonstrating ROI through a simple model. … In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in … The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention … Toolkit for reducing CAUTI in hospitals.
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - If you try and treat those common risk factors, then you will mitigate those harms in hospitals. … Our prior approach to falls was, “if we keep them in bed they won’t fall.” … We don’t want patients falling and breaking a bone while in the hospital under nurse supervision. … If a patient who is hospitalized for something, and is already quite debilitated, falls in the hospital … HW : SCL Health is made up of eight hospitals and over one hundred ambulatory sites in Colorado and Montana
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psnet.ahrq.gov/node/47849/psn-pdf
August 14, 2019 - The effect of external inspections on safety in acute
hospitals in the National Health Service in England … The effect of external inspections on safety in acute hospitals in the
National Health Service in England … https://psnet.ahrq.gov/issue/effect-external-inspections-safety-acute-hospitals-national-health-service … to evaluate hospital
safety. … did not improve rates of either pressure ulcers or falls.
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psnet.ahrq.gov/issue/hospitals-look-computers-predict-patient-emergencies-they-happen
June 16, 2021 - Citation Text:
Hospitals look to computers to predict patient emergencies before they happen. … This news article reports on how hospital logistics centers are working toward utilizing artificial intelligence … October 23, 2019
Health systems and hospitals in pursuit of high reliability. … May 1, 2019
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. … Acute Hospital Care Units
April 26, 2023
Algorithm that detects sepsis cut
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www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/event-summary-leveraging-data-enhance-cr-program.pdf
November 12, 2020 - Electronic medical record
(EMR) systems in use in
participating hospitals
Epic (47%)
Cerner … • Examining specific outcomes in the facility, such as the number of times patients are falling and … the location of the falls, can allow for improvement to facility conditions and safety in order to … Matt’s team traced increased falls back to changes in the gym
and track layout that allowed them to … make basic changes that reduced patient falls.
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psnet.ahrq.gov/issue/systematic-review-unintended-consequences-clinical-interventions-reduce-adverse-outcomes
November 15, 2023 - June 16, 2019
In-hospital sequelae of injurious falls in 24 medical/surgical units in … four hospitals in the United States. … January 25, 2017
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 … June 27, 2011
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See More About The Topic
Hospitals
Health Care … Providers
Medicine
Indwelling Tubes and Catheters
Patient Falls
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psnet.ahrq.gov/issue/patient-safety-ed
August 11, 2010 - Hospitals & health networks. 2006;80(5):6 p. following 48, 2. … Share
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June 17, 2014
Hospitals … Hospitals & health networks. 2006;80(5):6 p. following 48, 2. … March 27, 2018
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care … October 19, 2011
Fixing America's hospitals.
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psnet.ahrq.gov/issue/investigating-long-term-consequences-adverse-medical-events-among-older-adults
March 24, 2019 - September 27, 2023
Cost of inpatient falls and cost-benefit analysis of implementation … July 31, 2008
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries. … Australian hospitals: a mixed methods study. … June 13, 2011
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See More About The Topic
Hospitals
Risk Managers