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4781. What Exactly Is Patient Safety? (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Emanuel-Berwick_110.pdf
      July 02, 2008 - the 1990s was that, despite all the known power of modern medicine to cure and ameliorate illness, hospitals … the development of safer and more effective surgery, medical care delivery systems began focusing on hospitals … Certification of hospitals and other health care delivery systems followed, often with professional … For instance, patient safety designs can be thought of as falling into two types: those that are for … of intervention in one place in the system on other places in the system.

4782. Steps for Increasing Urinary Incontinence Screening: A Guide for Primary Care Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/mui/mui-screening-toolkit.pdf
      April 01, 2025 - • Increased risk of falls and fractures. … The University Hospitals of Cleveland’s EMPOWER team recognized the importance of securing buy- in … AHRQ MUI Grantee Example: EMPOWER UI Patient Questionnaire The University Hospitals of Cleveland’s … – Falls Risk Reduction: Primary care practices may have QI efforts to reduce the risk of falls and … electronic medical records with a multi-pronged strategy at a tertiary care hospital in Singapore.

4783. Connecting the Dots: Improving Unit Safety Culture to Stop HAI | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/connecting-dots-slides.html
      December 01, 2017 - between HSOPS average composite scores and a composite of patient safety indicators (PSIs) for 179 hospitals … /hosp-reports.html 1,128 hospitals; 567,703 respondents in 2012 database 42 items categorized … Problems often occur in the exchange of information across hospital departments... 50% 4. … Shift changes are problematic for patients in this hospital. 46% Slide 32 Action Planning: Interventions … A theory-driven longitudinal evaluation of the impact of team training on safety culture in 24 hospitals

4784. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | PSNet
      psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
      June 01, 2003 - hospitals.( 4 ) Seminal studies then demonstrated that increases in the number of RNs caring for patients … But even in hospitals with such staffing policies, situations will arise in which nurses find themselves … Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? … Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715-1722. … a children's hospital.

4785. Understanding Quality and Safety Problems in the Ambulatory Environment: Seeking Improvement With Promising Teamwork Tools and Strategies (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Webster_76.pdf
      July 18, 2008 - ambulatory procedures, which numbered 31.5 million in 1996.2 Compared to inpatient hospital care, the … reducing hospital admissions due to ADEs. … Interventions in primary care to reduce medication related adverse events and hospital admissions: … Deficits in communication and information transfer between hospital-based and primary care physicians … Falls Church, VA: TRICARE Management Activity; 2005.

4786. Achieving Excellence Across All CG-CAHPS Core Measures: Lessons from Top-Performing Medical Practices (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20141022_cg/lessons_from_top-performing_medical_practices_CG-CAHPS_transcript.pdf
      October 01, 2014 - As shown here, facility surveys include HCAHPS for hospitals as well as CAHPS for dialysis centers and … system, but all admit to the central hospital at Meriter Hospital there. … You could be a lab tech at the hospital. You could be a lab tech in another clinic. … And if that becomes the primary focus, everything else falls in place. Dale Shaller Very good. … With the CG- CAHPS that Mercy Hospital participates in, there are many questions that are more primary

4787. Implementing Heart Health Practice Self-Assessment (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/skills-qi-heart-health.docx
      February 01, 2016 - Proactively identify patients with unplanned hospital admissions and ED visits 11. … Share clinical information with admitting hospitals and emergency departments 12. … Consistently obtain patient discharge summaries from the hospital and other facilities 13. … Exchange patient information with a hospital during hospitalization Community Linkages Please … Evaluate the cost of work of other specialties that falls to primary care physicians, and consider ways

4788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837748/psn-pdf
      August 05, 2022 - In the MARQUIS study, five US hospitals implemented one to seven evidence-based interventions for 791 … However, this practice may not be feasible for some hospitals, so hospitals should first focus on hiring … Hospital-based medication reconciliation practices: a systemic review. … Society of Hospital Medicine. … of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals

4789. Disposition of Comments_Comparative Effectiveness Review No. 249: Malnutrition in Hospitalized Adults: A Systematic Review (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-249-malnutrition-disposition-comments_0_0.pdf
      October 13, 2021 - select hospitals. … hospitals. … the application of various tools in hospitals. … Finally, in many hospitals (and in many studies), patients receive nutrition intervention regardless … The skeleton in the hospital closet 1974.

4790. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840174/psn-pdf
      August 28, 2024 - Hospital staff then offered confidential peer-to-peer support to the surgeon and others involved in … Who from the hospital will attend the meeting? … least her point of contact (social worker/liaison), the involved physician(s), a representative of hospital … leadership, and a hospital lawyer should attend. … institution apologize for an event that caused them profound pain, and that could lead them and the hospital

4791. Missed CANDOR Implementation Opportunities. | PSNet
      psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
      November 11, 2020 - Hospital staff then offered confidential peer-to-peer support to the surgeon and others involved in the … Who from the hospital will attend the meeting? … least her point of contact (social worker/liaison), the involved physician(s), a representative of hospital … leadership, and a hospital lawyer should attend. … May 1, 2006 View More See More About The Topic Hospitals Health

4792. Surgical Safety: Addressing the JCAHO Goals for Reducing Wrong-site, Wrong-patient, Wrong-procedure Events (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Ludwick.pdf
      June 21, 2004 - Surgical verification checklist—Naval Hospital, Cherry Point, NC Naval Hospital Cherry Point Surgical … any area of the hospital. … differences in various areas of the hospital, it leaves the development of department policy to the … Author affiliation The author is affiliated with the Naval Hospital, Cherry Point, NC. … Surgical verification checklist—Naval Hospital, Cherry Point, NC Figure 2.

4793. Archived: Evidence Summary: Osteoporosis: Screening, 2002 | United States Preventive Services Taskforce
      www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/osteoporosis-screening-2002
      September 17, 2002 - fractures are detected only incidentally on radiography, some cause severe pain, leading to 150,000 hospital … risk factors, such as psychomotor impairment, poor gait, and other factors that increase the risk for falling … effect on hip fracture rates among women 80 years of age or older who had one or more risk factors for falls … Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. … Clinic visits and hospital admissions for care of acid-related upper gastrointestinal disorders in women

4794. Final Progress Report: Real-time assessment of risk factors for medication errors (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/dresselhaus-report.pdf
      January 01, 2024 - Our objective was to assess risk factors for medication errors in four academic hospitals using ecological … The reported incidence of errors in medication treatment for adults ranges from 1% to 30% of all hospital … hospitals. … These hospital-based incident and occurrence reporting mechanisms remained in place during the duration … The study was conducted in the inpatient settings of four affiliated academic hospitals.

4795. Topic-Brief1-Care-Coordination (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/pdf/topic-brief1-care-coordination.pdf
      April 01, 2021 - In addition, the ERAS protocols focused primarily on management from surgery until hospital discharge … Among opioid-naïve patients admitted to the hospital, 15 to 25 percent fill an opioid prescription in … In persons with pain, transitions of care from the hospital to home or a nursing facility can result … The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality … Falling through the cracks: challenges and opportunities for improving transitional care for persons

4796. Topic-Brief1-Care-Coordination (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/topic-brief1-care-coordination.pdf
      April 01, 2021 - In addition, the ERAS protocols focused primarily on management from surgery until hospital discharge … Among opioid-naïve patients admitted to the hospital, 15 to 25 percent fill an opioid prescription in … In persons with pain, transitions of care from the hospital to home or a nursing facility can result … The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality … Falling through the cracks: challenges and opportunities for improving transitional care for persons

4797. Evidence Summary-Comparative-Effectiveness-Review-213-Lower-Limb-Prostheses (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-213-lower-limb-protheses-evidence-summary.pdf
      September 01, 2018 - for test accuracy to predict two or more falls during a 6-month followup period.7 The Turn Time and … Test, FSST and TUG all had high sensitivity (85% to 100%) and specificity (74% to 93%) to predict falls … Advanced components portion of LCI-4 had high specificity (91%) but low sensitivity (43%) to predict falls … of the 180 Degree Turn Test also had high sensitivity (85%) but low sensitivity (31%) to predict falls … However, only one of the studies was conducted in the United States and it used hospital data as of

4798. Pocket Syringe Swap | PSNet
      psnet.ahrq.gov/web-mm/pocket-syringe-swap
      July 01, 2006 - In some studies, an error is counted only if there is identifiable patient harm ( 3 ); in others an error … , administer, and document medications without any of the checks and balances routinely employed on hospital … drug safety in anesthesia. … Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. … Developing a Successful Hospital Safety Program July 1, 2006 WebM

4799. Shortcuts to Acetaminophen-induced Liver Failure | PSNet
      psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
      July 01, 2017 - The patient was admitted to the hospital and given broad-spectrum antibiotics and a diagnosis of "influenza … Bacak, DO, MPH Maternal–Fetal Medicine Specialist Akron Children's Hospital Assistant Professor of Ob … of Ob/Gyn Division of Maternal–Fetal Medicine University of Rochester Medical Center/Strong Memorial Hospital … in rats in vivo. … a multistate hospital network--13 academic medical centers, April-June 2020.

4800. Testimony for the House Energy and Commerce Health Subcommittee Hearing (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/tfcongresstestimony%20(3).pdf
      November 30, 2016 - In our current prostate cancer update, for example, in addition to the methodological experts from the … in the widespread adoption of our guidance to inform care in many health systems. … I am also a general internist who provides primary care to adult patients at the public hospital in San … Francisco—Zuckerberg San Francisco General Hospital. … in the widespread adoption of our guidance to inform care in many health systems.