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1721. A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. | PSNet
      psnet.ahrq.gov/issue/partially-structured-postoperative-handoff-protocol-improves-communication-2-mixed-surgical
      November 19, 2018 - December 23, 2020 Patient safety implications of wearing a face mask for prevention in

1722. Four New York Providers Use AHRQ Medication Reconciliation Toolkit to Improve Care | Agency for Healthcare Research and Quality
      www.ahrq.gov/news/newsroom/case-studies/ktcquips86.html
      October 01, 2014 - Glens Falls Hospital in Glens Falls, New York, entered the collaborative with a "One Source of Truth … Nancy Huntington, PharmD, Director of Pharmacy, reported, "It is Glens Falls' intent to actively use

1723. Weak oversight allows lab failures to put patients at risk. | PSNet
      psnet.ahrq.gov/issue/weak-oversight-allows-lab-failures-put-patients-risk
      June 12, 2019 - March 11, 2020 Preventing falls and fall-related injuries in health care facilities.

1724. 4 skin conditions doctors often misdiagnose. | PSNet
      psnet.ahrq.gov/issue/4-skin-conditions-doctors-often-misdiagnose
      September 30, 2020 - case-control study March 11, 2020 Sitters as a patient safety strategy to reduce hospital falls

1725. Tool: Check-Back (or Repeat-Back) | Agency for Healthcare Research and Quality
      www.ahrq.gov/teamstepps-program/curriculum/communication/tools/checkback.html
      July 01, 2023 - Other examples of effective check-backs include: One member of the team calls out, "BP is falling … BP is falling and at 80/48, down from 90/60." 

1726. 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 - Blood Thinner Pills: Your Guide to Using Them Safely The Agency for Healthcare Research and Quality offers a free booklet and a video about blood thinner medicines. Staying Active and Healthy with Blood Thinners , a 10-minute video, features easy-to-understand explanations of how blood thinners wor…

1727. Refused Medication Error | PSNet
      psnet.ahrq.gov/web-mm/refused-medication-error
      November 01, 2005 - , Right Away August 21, 2016 WebM&M Cases Falling

1728. Mismanagement of Delirium | PSNet
      psnet.ahrq.gov/web-mm/mismanagement-delirium
      February 13, 2014 - By history, this patient exhibited features of parkinsonism (shuffling gait and falls), disturbed nighttime … The care of a person with dementia should be focused on prevention of delirium (for example, promotion … Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5:210-220. … impairment Advancing age (> 65 years) History of delirium, stroke, neurological disease, falls

1729. Reducing Unecessary Urinary catheter Use in the Emergency Department: How to Implement the Process (ppt file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/ed-catheter-insertions-091013.ppt
      January 01, 2010 - He gets more restless, gets out of bed, trips on the catheter and falls. … We traditionally thought that a catheter was helpful in preventing falls because patients didn’t have … However, the catheter doesn’t eliminate the urge to urinate and the tubing can cause tripping and falling … In prevention of CAUTI, this communication is vital. Discuss the indications.

1730. EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs4-infection-prevention-mdro-protocol.pdf
      July 01, 2023 - Evidence-based Practice Center Rapid Review Protocol Project Title: Making Healthcare Safer IV: Prevention … resistant organisms (MDROs). 3 Overview of the PSP Several major categories of MDRO infection prevention … However, a preliminary search of COVID-19 infection prevention studies yielded >13,000 titles, far … Noninfectious adverse healthcare- associated outcomes (hospital- acquired pressure injuries, inpatient falls … Global Strategy on Infection Prevention and Control.

1731. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50939/psn-pdf
      February 26, 2020 - to improve healthcare quality and mitigate and prevent harm from homecare safety incidents such as falls

1732. Experts' perspectives on use of fast healthcare interoperable resources for computerized clinical decision support. | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/shareable-interoperable-clinical-decision-support-older-adults-advancing-fall/citation/experts
      January 01, 2023 - Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall Assessment and Prevention

1733. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
      July 01, 2011 - anticoagulants 3 4 Case: Watch the Warfarin A frail 80-year-old man with a past medical history of dementia, falls … Cost-effectiveness of dabigatran compared with warfarin for stroke prevention in atrial fibrillation.

1734. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73302/psn-pdf
      May 26, 2021 - We're able to, like you mentioned, track and record things like falls in EMS, a patient falling from … organization are tracking any patient safety errors, but I would like to know what the percentage of falls … leaders, and it enables us to say that we need to be at the table to talk about things like patient falls

1735. Primers | PSNet
      psnet.ahrq.gov/primers-0
      March 15, 2025 - 2) Medical Complications (10) Nosocomial Infections (6) Patient Falls … Retained Surgical Items: Causation and Prevention Verna Gibbs, MD and Patrick Romano, MD, MPH | … RSI prevention efforts should focus on improving surgical item management and enhancing effective communication

1736. Nursing Home Workplace Safety Resource List (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
      January 01, 2023 - CDC’s Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings … Preventing the Spread of COVID-19 https://www.ahrq.gov/nursing-home/materials/prevention/index.html … Centers for Disease Control and Prevention (CDC) Resources a. … • Hazard prevention and control. • Safety and health training. … living administrators, which covers healthcare topics from patient safety handling to slips, trips, and falls

1737. Medical Errors | Agency for Healthcare Research and Quality
      www.ahrq.gov/topics/medical-errors.html
      Advances in Patient Safety AHRQ Toolkit Helped Madonna Rehabilitation Hospital Reduce Patient Falls

1738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41470/psn-pdf
      November 15, 2024 - Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention

1739. Quality and Patient Safety. | PSNet
      psnet.ahrq.gov/issue/quality-and-patient-safety
      December 24, 2008 - June 28, 2018 Fall Prevention in Hospitals Training Program.

1740. Infectious Complications Related to the Catheter Other Than CAUTI | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/infectious-complications-slides.html
      December 01, 2017 - Complications Related to the Catheter Other than CAUTI Mohamad Fakih, MD, MPH Medical Director, Infection Prevention … unnecessary antibiotic use in causing C. difficile infection Summarize the role of unit culture on prevention … Slide 31 How Culture Plays a Role in CAUTI Prevention Kathlyn E. … Workload issues leading to work-arounds Weighing risk of catheters v. other issues (i.e. falls) … Slide 35 Our Qualitative Study Goal: To understand unit-level culture around CAUTI prevention