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psnet.ahrq.gov/node/36244/psn-pdf
June 13, 2012 - incidents were from inpatient mental health facilities, primarily
involving patient accidents (including falls
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psnet.ahrq.gov/issue/ashp-guidelines-preventing-medication-errors-chemotherapy-and-biotherapy
September 07, 2016 - Organizational Policy/Guidelines
ASHP guidelines on preventing medication errors with chemotherapy and biotherapy.
Citation Text:
Goldspiel B, Hoffman JM, Griffith NL, et al. ASHP guidelines on preventing medication errors with chemotherapy and biotherapy. Am J Health Syst Pharm. 2015;72…
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psnet.ahrq.gov/issue/cardiac-surgical-icu-care-eliminating-preventable-complications
August 04, 2021 - Review
Cardiac surgical ICU care: eliminating "preventable" complications.
Citation Text:
Shake JG, Pronovost P, Whitman GJR. Cardiac surgical ICU care: eliminating "preventable" complications. J Card Surg. 2013;28(4):406-13. doi:10.1111/jocs.12124.
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Format:
D…
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psnet.ahrq.gov/issue/technology-and-error-prevention-strategies-why-are-we-still-overlooking-iv-room
July 08, 2015 - Newspaper/Magazine Article
Technology and error-prevention strategies: why are we … Citation Text:
Technology and error-prevention strategies: why are we still overlooking the IV room … URL
Cite
Citation
Citation Text:
Technology and error-prevention
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psnet.ahrq.gov/issue/health-care-leaders-action-guide-hospital-strategies-reducing-preventable-mortality
May 06, 2015 - May 24, 2015
Preventing Patient Falls: A Systematic Approach From the Joint Commission
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - since
experienced higher rates of preventable infections, as well as increases in pressure ulcers and falls … performance measures are associated with measuring and reporting
specific harms, such as an infection, falls … dynamic reality, reorienting focus from performance measures of harm to measures that
reflect risk prevention … nursing homes across the United States to increase the implementation
of evidence-based infection prevention … with our work to radically reorient our thinking and approach to safety to place more emphasis on
prevention
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
Learning From Defects
ICU & Non-ICU
Slide Title and Commentary … For instance, the unit and the infection prevention team may detect that MRSA has been transmitted from … A factor that falls in the category of being a minor reason for the defect and rarely occurs may not … Regarding low hand hygiene adherence, the infection prevention and unit leadership team was tasked to … No. 25-0007
October 2024
Learning From Defects
| 1
AHRQ Safety Program for MRSA Prevention | ICU &
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psnet.ahrq.gov/node/60280/psn-pdf
April 29, 2020 - the biggest threat to patient
safety resulting from missed, rationed or unfinished care, and that falls
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psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis
March 10, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls
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psnet.ahrq.gov/issue/implementing-human-factors-approach-rca2-tools-processes-and-strategies
July 21, 2021 - October 28, 2020
Patient falls in the operating room setting: an analysis of reported
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psnet.ahrq.gov/issue/advancing-nursing-home-quality-through-quality-improvement-itself
November 28, 2018 - May 15, 2019
Utilizing quality improvement methods to prevent falls and injury from falls
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psnet.ahrq.gov/issue/implementation-rapid-response-team-decreases-cardiac-arrest-outside-intensive-care-unit
September 26, 2012 - Study
Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit.
Citation Text:
Offner PJ, Heit J, Roberts R. Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. J Trauma. 2007;62(5):1223-7; disc…
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psnet.ahrq.gov/issue/health-care-worker-fatigue-and-patient-safety
December 23, 2016 - February 10, 2021
Preventing falls and fall-related injuries in health care facilities
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psnet.ahrq.gov/issue/association-between-electronic-health-record-implementations-and-hospital-acquired-conditions
September 01, 2016 - October 13, 2010
View More
Related Resources
Reducing falls in … Pediatrics
Medication Errors/Preventable Adverse Drug Events
Nosocomial Infections
Patient Falls
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psnet.ahrq.gov/issue/theory-driven-longitudinal-evaluation-impact-team-training-safety-culture-24-hospitals
October 16, 2019 - Study
A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals.
Citation Text:
Jones KJ, Skinner AM, High R, et al. A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 20…
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psnet.ahrq.gov/issue/impact-age-anaesthesiologists-competence-narrative-review
December 15, 2014 - December 15, 2014
Effects of an intervention to increase bed alarm use to prevent falls … April 2, 2008
Is it possible to identify risks for injurious falls in hospitalized patients
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psnet.ahrq.gov/issue/patient-risk-factors-medical-injury-case-control-study
April 12, 2011 - September 25, 2011
Fall prevention in acute care hospitals: a randomized trial.
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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 … Hospitals
Health Care Providers
Medicine
Indwelling Tubes and Catheters
Patient Falls
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psnet.ahrq.gov/issue/virtual-patients-designed-training-against-medical-error-exploring-impact-decision-making
May 15, 2024 - June 3, 2020
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/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
November 15, 2023 - October 18, 2023
Fall prevention with the Smart Socks System reduces hospital fall rates