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1841. Patient Safety and Adverse Events, 2011 and 2014 (pdf file)
      hcup-us.ahrq.gov/reports/statbriefs/sb237-Patient-Safety-Adverse-Events-2011-2014.pdf
      January 01, 2014 - Among the selected PSIs, average hospital rates for in-hospital falls with hip fracture decreased … of central venous catheter- related blood stream infections (64.2 percent) followed by in-hospital falls … Among the selected patient safety and adverse events, average hospital rates for in-hospital falls with … These problems are likely amenable to prevention by changes at the system or provider levels. … The AHRQ QI modules include Prevention Quality Indicators, Inpatient Quality Indicators, Patient Safety

1842. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes. | PSNet
      psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two
      February 16, 2022 - February 16, 2022 Information flow during pediatric trauma care transitions: things falling … Patient Safety Primers Retained Surgical Items: Causation and Prevention

1843. Healthcare Cost and Utilization Project (HCUP) NEDS Notes
      hcup-us.ahrq.gov/db/vars/intent_self_harm/nedsnote.jsp
      May 01, 2015 - self harm is consistent with the classification system used by the Centers for Disease Control and Prevention … also includes 11 data elements that identify the mechanism of the injury: cutting/piercing, drowning, falling

1844. Preparing for and Recovering After Hip or Knee Replacement Surgery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/booklets/hip-knee-surgery-booklet.pdf
      November 01, 2023 - Preparing for and Recovering After Hip or Knee Replacement Surgery Preparing for and Recovering After Hip or Knee Replacement Surgery e Hip or Knee Replacement Surgery Patient Education Guide 1 Preparing for and Recovering After Hip or Knee Replacement Surgery Patient Name ______________________________…

1845. Preventable deaths in patients admitted from emergency department. | PSNet
      psnet.ahrq.gov/issue/preventable-deaths-patients-admitted-emergency-department
      September 27, 2017 - Study Preventable deaths in patients admitted from emergency department. Citation Text: Lu T-C, Tsai C-L, Lee C-C, et al. Preventable deaths in patients admitted from emergency department. Emerg Med J. 2006;23(6):452-5. Copy Citation Format: Google Scholar PubMed BibTeX E…

1846. Emergency department crowding and risk of preventable medical errors. | PSNet
      psnet.ahrq.gov/issue/emergency-department-crowding-and-risk-preventable-medical-errors
      November 23, 2011 - March 19, 2019 Evaluation of clinical practice guidelines on fall prevention and management

1847. Can a structured checklist prevent problems with laparoscopic equipment? | PSNet
      psnet.ahrq.gov/issue/can-structured-checklist-prevent-problems-laparoscopic-equipment
      August 10, 2016 - medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention … May 26, 2011 Evaluation of clinical practice guidelines on fall prevention and management

1848. Clinical features and preventability of delayed diagnosis of pediatric appendicitis. | PSNet
      psnet.ahrq.gov/issue/clinical-features-and-preventability-delayed-diagnosis-pediatric-appendicitis
      September 13, 2023 - January 4, 2021 Evaluation of clinical practice guidelines on fall prevention and management

1849. Exercise Handouts w/ Drawings (pdf file)
      cds.ahrq.gov/sites/default/files/cds/artifact/127731/FallPreventionFoundationalExercises.pdf
      July 18, 2023 - Daily Fall Prevention Exercises - Level 1 Standing Exercises Sit to Stand (do this 5 to 10 times)A

1850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73484/psn-pdf
      July 14, 2021 - The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective advocates. July 14, 2021 Silvera GA, Wolf JA, Stanowski A, et al. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective a…

1851. Resources and Tools on Patient and Healthcare Workforce Safety | Agency for Healthcare Research and Quality
      www.ahrq.gov/action-alliance/resources/index.html
      March 01, 2025 - Workforce Safety Learning Systems Resources by Safety Topic Diagnostic Safety  Emergency Preparedness Falls

1852. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
      www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
      June 01, 2023 - Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action OR-to-ICU Transitions Previous Page Next Page Table of Contents Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action Introd…

1853. SOPS Bibliography | Agency for Healthcare Research and Quality
      www.ahrq.gov/sops/bibliography/index.html?page=3
      January 01, 2025 - Improving hospital safety culture for falls prevention through interdisciplinary health education.

1854. SOPS Bibliography | Agency for Healthcare Research and Quality
      www.ahrq.gov/es/sops/bibliography/index.html?page=3
      January 01, 2025 - Improving hospital safety culture for falls prevention through interdisciplinary health education.

1855. Module 1. Detecting Change in a Resident's Condition | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1.html
      March 01, 2018 - Falls Prevention Appendix 1-A. Suggested Slides for Module 1 Appendix 1-B. … Educate the entire staff about the importance of falls, risk factors for residents, and methods of prevention … stretch" goal that may be hard to reach but is achievable—for example: Decrease the rate of resident falls … responsible member of the center in order to ensure that the improvement is sustained over time and, if it falls

1856. Nursing home patient safety culture perceptions among licensed practical nurses. | PSNet
      psnet.ahrq.gov/issue/nursing-home-patient-safety-culture-perceptions-among-licensed-practical-nurses
      February 17, 2021 - Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention

1857. Linking patient safety culture to quality ratings in the nursing home setting. | PSNet
      psnet.ahrq.gov/issue/linking-patient-safety-culture-quality-ratings-nursing-home-setting
      June 29, 2022 - Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention

1858. Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke. | PSNet
      psnet.ahrq.gov/issue/identifying-errors-and-safety-considerations-patients-undergoing-thrombolysis-acute-ischemic
      February 09, 2022 - March 29, 2023 Fall prevention with the Smart Socks System reduces hospital fall

1859. Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward. | PSNet
      psnet.ahrq.gov/issue/less-more-project-reduce-number-pims-potentially-inappropriate-medications-elderly-care-ward
      September 27, 2017 - June 1, 2012 Utilizing quality improvement methods to prevent falls and injury from falls

1860. Readmissions, observation, and the Hospital Readmissions Reduction Program. | PSNet
      psnet.ahrq.gov/issue/readmissions-observation-and-hospital-readmissions-reduction-program
      October 25, 2017 - September 29, 2017 Preventing falls and fall-related injuries in health care facilities