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psnet.ahrq.gov/issue/user-centered-collaborative-design-and-development-inpatient-safety-dashboard
July 24, 2017 - an AHRQ-funded project to develop an interactive web-based dashboard to communicate patient data in … November 15, 2018
Prevalence and causes of diagnostic errors in hospitalized patients … July 29, 2020
Cost of inpatient falls and cost-benefit analysis of implementation of … February 1, 2023
Evaluation of a patient-centered fall-prevention tool kit to reduce falls … March 1, 2017
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Hospitals
Facility
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psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide
December 06, 2017 - April 22, 2011
Families as partners in hospital error and adverse event surveillance. … November 25, 2015
Improving medication administration safety in a community hospital … March 27, 2013
Utilizing quality improvement methods to prevent falls and injury from … falls: enhancing resident safety in long-term care. … February 1, 2012
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Hospitals
Health
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psnet.ahrq.gov/issue/identifying-right-patient-nurse-and-consumer-perspectives-verifying-patient-identity-during
September 03, 2011 - September 3, 2011
Effects of an intervention to increase bed alarm use to prevent falls … December 12, 2012
Effect of nonpayment for preventable infections in U.S. hospitals. … April 5, 2013
Is it possible to identify risks for injurious falls in hospitalized patients … March 3, 2019
What causes medication administration errors in a mental health hospital … October 6, 2016
Supporting a psychiatric hospital culture of safety.
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psnet.ahrq.gov/node/43524/psn-pdf
October 29, 2014 - Validating administrative data for the detection of adverse
events in older hospitalized patients. … Validating administrative data for the detection of adverse events in
older hospitalized patients. … administrative data for hospital-related complications
such as pressure ulcers, falls, and adverse … drug events accurately reflect the presence of these events in
the medical record. … preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - At the hospital, a full examination revealed a very deep pressure ulcer in her sacrum (stage IV full … in hospitals.( 6 ) However, comparing adverse events across health care settings is difficult at best … With each transfer her condition worsened until her death in the hospital. … Adverse Events in Hospitals: Overview of Key Issues. Report no. OEI-06-07-00470. December 2008. … awaiting long-term care in hospital.
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psnet.ahrq.gov/node/841144/psn-pdf
December 07, 2022 - Using community detection techniques to identify themes
in COVID-19-related patient safety event reports … Using community detection techniques to identify themes in
COVID-19-related patient safety event reports … new categories and
themes in patient safety reporting. … eight clinically relevant themes, including testing delays, diagnostic errors,
pressure ulcers, and falls … https://psnet.ahrq.gov/issue/patient-safety-concerns-covid-19-related-events-study-343-event-reports-71-hospitals
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psnet.ahrq.gov/issue/checklists-improve-patient-safety
July 31, 2013 - includes 10 checklists that integrate best practices into care processes to prevent variations in … May 6, 2015
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final … October 19, 2016
Hand Hygiene Project: Best Practices from Hospitals Participating in … May 24, 2015
Preventing Patient Falls: A Systematic Approach From the Joint Commission … July 9, 2012
Adequacy of hospital discharge summaries in documenting tests with pending
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psnet.ahrq.gov/issue/suicidal-patient-slips-through-cracks
November 26, 2013 - offers two levels of examination of a hypothetical patient suicide: one that outlines points of failure in … July 22, 2020
America's Hospitals: Improving Quality and Safety—The Joint Commission's … April 24, 2024
WebM&M Cases
Walking Out of a Hospital … 27, 2023
Patient Safety Innovations
Preventing Falls … December 23, 2016
Inpatient suicide and suicide attempts in Veterans Affairs hospitals
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psnet.ahrq.gov/issue/errors-upstream-and-downstream-universal-protocol-associated-wrong-surgery-events-veterans
November 21, 2012 - Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in … Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the … November 21, 2012
Root cause analysis of reported patient falls in ORs in the Veterans … January 17, 2019
Root cause analysis of reported patient falls in ORs in the Veterans … of Veterans Affairs hospitals.
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psnet.ahrq.gov/node/45453/psn-pdf
November 02, 2016 - Creating highly reliable health care: how reliability-
enhancing work practices affect patient safety in … hospitals. … employees mechanisms to recommend
organizational change, is associated with fewer medication errors and falls
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psnet.ahrq.gov/issue/health-care-leader-action-guide-reduce-avoidable-readmissions
March 14, 2018 - This guide introduces strategies for hospital managers to prevent avoidable readmissions . … Hospitals, 2010 Versus 2014. … October 23, 2019
Origin of Adverse Drug Events in US Hospitals, 2011. … October 9, 2013
Hand Hygiene Project: Best Practices from Hospitals Participating in … 31, 2024
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - In fact, Dall et al., 2009, found that there
were economic benefits to hospitals with better staffing … One classic study showed lower
inpatient mortality rates for a variety of surgical patients in hospitals … Beginning in 1983, the program sought to identify hospitals which had lower turnover
rates and above … Effect of changes in hospital nursing resources on
improvements in patient safety and quality of care … Correlates and predictors of missed nursing care in
hospitals.
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psnet.ahrq.gov/issue/staying-safe-while-getting-well
February 05, 2014 - Patients can help minimize the potential for adverse events while in the hospital. … March 20, 2024
Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital … complications: a medical record review across nine Swiss hospitals. … January 10, 2024
Patient Safety Innovations
Preventing Falls … But are hospitals getting any safer?
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - compliance—a key factor associated with the spread of HAI.( 10 ) Bronson Methodist Hospital in Kalamazoo … Because most studies in this area have involved multifaceted-interventions to reduce falls ( 17-19 ), … Systematic review of studies on compliance with hand hygiene guidelines in hospital care. … The impact of healthcare environmental design on patient falls. … Health Care
August 1, 2009
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Hospitals
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psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
February 11, 2015 - Hospitals. … February 11, 2015
Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced … May 25, 2022
Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events … October 29, 2008
Home Health Agencies Failed To Report Over Half of Falls With Major … November 8, 2023
Patient Safety Organizations: Hospital Participation, Value, and Challenges
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psnet.ahrq.gov/issue/scottish-patient-safety-alliance
July 29, 2015 - September 28, 2023
Hospital Compare. … April 24, 2013
Minnesota Hospital Association Statewide Project: SAFE from FALLS. … Hospital Care. … October 12, 2011
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries … September 20, 2011
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Hospitals
Health
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psnet.ahrq.gov/issue/procedures-should-promote-patient-safety
March 01, 2007 - Hospital peer review. 2006;31(8):113-6. … This article discusses the importance of developing practical procedures in hospital care and how to … Related Resources
Patient Safety Innovations
Preventing Falls … hospital safety: a systematic review and meta-analysis of hospital adverse events. … best practices in US hospitals.
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psnet.ahrq.gov/issue/audit-missed-or-delayed-antimicrobial-drugs
August 01, 2012 - hospital settings in the United Kingdom. … Hospitals Were Reported to State Adverse Event Reporting Systems. … August 1, 2012
Adverse Events in Hospitals: Public Disclosure of Information About Events … delays to identification of serious injury after falls in hospital inpatients. … May 13, 2009
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Hospitals
Physicians
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psnet.ahrq.gov/issue/program-encourages-reporting-accidents-waiting-happen-good-catch-awards
February 13, 2013 - Minnesota Hospital Association. … Minnesota Hospital Association. … A COVID-19 Resource for Hospital and Health System Leaders. … July 23, 2024
Patient Safety Innovations
Preventing Falls … September 9, 2010
Fixing America's hospitals.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
September 01, 2011 - She immediately complained of hip pain and was transferred to an acute care hospital. … Because of concerns for an acute infection, she was transferred to an acute care hospital. … *
*
Case: Safety of Long-Term Care (4)
At the hospital, a full examination revealed a very deep … focused on pressure ulcers, adverse drug events (ADEs), and falls
Data regarding incidence of adverse … Comparing the safety culture of nursing homes and hospitals. J Appl Gerontol. 2011;30:22-43.