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psnet.ahrq.gov/issue/adverse-event-reporting-tool-standardize-reporting-and-tracking-adverse-events-during
April 20, 2016 - April 20, 2016
Primary care–relevant interventions to prevent falling in older adults … December 14, 2010
Practice advisory for the prevention and management of operating room
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psnet.ahrq.gov/node/43068/psn-pdf
May 29, 2014 - interdisciplinary-team-members
Examining patient safety in home hospice care, the authors found that falls … identification-serious-and-reportable-events-home-care-delphi-survey-develop-consensus
https://psnet.ahrq.gov/issue/primary-care-relevant-interventions-prevent-falling-older-adults-systematic-evidence-review
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-alternatives.pptx
April 01, 2022 - incontinence when nurses can turn/provide skin care
Routine use to manage incontinence
To reduce risk of falls … Guideline for prevention of catheter-associated urinary tract infections 2009. … Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - event as preventable requires some judgment about the degree to which the evidence supports specific prevention … Preventable adverse events : those that occurred due to error or failure to apply an accepted strategy for prevention … if care had been different; Adverse events due to negligence : those that occurred due to care that falls
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan29/diet-behavioral-counseling-primary-care-adults-2003
February 03, 2014 - providing controlled diets
Counseling interventions aimed at weight loss or weight maintenance, falls … prevention, depression, cognitive functioning, or disease prevention other than CVD/diabetes mellitus
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psnet.ahrq.gov/issue/open-better-care
January 28, 2015 - The initiative aims to build collaborative programs across New Zealand to reduce falls , health care–associated … December 22, 2021
Utilizing quality improvement methods to prevent falls and injury from … falls: enhancing resident safety in long-term care.
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psnet.ahrq.gov/issue/impact-computerized-prescriber-order-entry-incidence-adverse-drug-events-pediatric-inpatients
October 19, 2022 - November 16, 2022
Evaluation of clinical practice guidelines on fall prevention and management … May 27, 2011
Effect of computer order entry on prevention of serious medication errors
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hcup-us.ahrq.gov/reports/statbriefs/sb19.pdf
November 01, 2006 - definition of injury used in this statistical brief is consistent with the State and
Territorial Injury Prevention … Over 38 per-
f injury stays were the
of falls. … By far, the most frequent
cause of injury was falls. … Statistical Brief, injuries were defined in a manner consistent with the State and Territorial Injury
Prevention … State and Territorial Injury Prevention Directors Association. http://stipda.org/associations/5805/files
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Campbell-R_106.pdf
April 14, 2008 - It has established an international reputation in the areas of falls and safe
patient handling and movement … Because of the recognized chance of certain medications to
increase the risk of injurious falls in the … scientific and data gathering activities relating to the detection, assessment, understanding, and
prevention … WHO report as “the science and activities relating to the
detection, assessment, understanding, and prevention … Drugs and
falls in community-dwelling older people: A national
veterans study.
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psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
April 27, 2019 - Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Citation Text:
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
https://psnet.ahrq.gov/primer/maternal-safety
https://psnet.ahrq.gov/primer/falls … serious harm or death, easily identifiable and
https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery
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psnet.ahrq.gov/issue/what-every-graduating-resident-needs-know-about-quality-improvement-and-patient-safety
March 29, 2023 - December 18, 2017
Root cause analysis and actions for the prevention of medical errors
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pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in OIG Report as Clearly Preventable or Likely Preventable by Clinical Category
Page 1 of 4
Adverse and Temporary Harm Events in Rehabilitation
Hospitals Designated in Office of Inspector General Report1
as Clearly Preventable or Likely Pr…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - client, including
vital signs (e.g., blood pressure, pulse rate), other clinical indicators (e.g., falls … antidepressants, sleep aids, or other psychotropic drugs in
clients with signs of confusion, a history of falls … in the San Fernando and
Antelope Valleys, one in Santa Barbara and one in Kern County), a disease prevention … health systems, university
pharmacist training programs, post-acute care transition programs, and fall prevention … review
of medications, improved adherence to medications for chronic illnesses, reducing risks for falls
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psnet.ahrq.gov/node/42083/psn-pdf
March 13, 2013 - Progress in patient safety improvement has been hindered by a lack of high-quality research on error
prevention … certain health care–associated infections and surgical
complications, bundled interventions to reduce falls … surgical-safety-checklist-reduce-morbidity-and-mortality-global-population
https://psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - safety, facilitating clinician communication, as well as preventing hospital-associated infections, falls … A nursing care center goal includes preventing falls in patients and nursing home residents by identifying … individuals at risk for falls, such as those taking medications that could result in weakness, dizziness … The goal additionally includes taking steps to prevent falls in these high-risk individuals.
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psnet.ahrq.gov/node/43444/psn-pdf
August 27, 2014 - Kingdom revealed that the most common events included failure to recognize clinical deterioration, falls … improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
https://psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
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psnet.ahrq.gov/node/47349/psn-pdf
January 30, 2019 - information sharing and advice networks on several patient safety outcomes, including medication errors,
falls … //psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
https://psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
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hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/or31.jsp
August 01, 2014 - Motor vehicle crashes account for majority of unintentional injury deaths
Injury prevention … Falls: AI/AN 8.5, white 27.6. Accidental drowning:AI/AN 4.2, white 3.2. … projects at NPAIHB
Injury Prevention Program
NW Tribal Injury Prevention … Coalition → 5-year Tribal Injury Prevention Action Plan
Focus on motor vehicle safety & elder falls … Bridget Canniff & Luella Azule, Injury Prevention Program
Tam Lutz, Jodi Lapidus, & Nicole Smith, Native
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psnet.ahrq.gov/issue/clinicians-perceptions-opioid-error-contributing-factors-inpatient-palliative-care-services
June 01, 2016 - The impact of safety culture, quality of care, missed care and nurse staffing on patient falls … 27, 2024
Patient Safety Innovations
Preventing Falls … Through Patient and Family Engagement to Create Customized Prevention Plans
May 31, 2023