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psnet.ahrq.gov/issue/barriers-and-facilitators-bedside-nursing-handover-systematic-review-and-meta-synthesis
August 25, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls
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psnet.ahrq.gov/issue/pediatric-trainee-perspectives-decision-disclose-medical-errors
April 27, 2022 - interventions to reduce duration and variability in delays to identification of serious injury after falls … Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls
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psnet.ahrq.gov/issue/crying-wolf-alarm-safety-and-management-paediatrics-scoping-review
April 24, 2018 - Review
Crying wolf, alarm safety and management in paediatrics: a scoping review.
Citation Text:
Cole R, Roderick G, Cheema O, et al. Crying wolf, alarm safety and management in paediatrics: a scoping review. J Adv Nurs. 2024;Epub Sep 25. doi:10.1111/jan.16398.
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psnet.ahrq.gov/issue/patient-safety-factors-and-perceived-consequences-nursing-errors-nursing-staff-home-care
May 18, 2022 - Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention
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psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis
June 21, 2017 - The most common incidents were falls and delayed response to clinical deterioration. … November 21, 2012
Root cause analysis of reported patient falls in ORs in the Veterans
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psnet.ahrq.gov/issue/patient-safety-and-image-transfer-between-referring-hospitals-and-neuroscience-centres-could
July 19, 2023 - December 14, 2022
Fall prevention with the Smart Socks System reduces hospital
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psnet.ahrq.gov/issue/effect-facility-characteristics-patient-safety-patient-experience-and-service-availability
April 12, 2023 - November 12, 2014
Patient falls in the operating room setting: an analysis of reported
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psnet.ahrq.gov/issue/stoppstart-criteria-potentially-inappropriate-medications-potential-prescribing-omissions
January 19, 2022 - perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls … March 6, 2012
Potentially inappropriate medications and their effect on falls during
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psnet.ahrq.gov/issue/pharmacist-led-program-improve-transitions-acute-care-skilled-nursing-facility-care
December 09, 2020 - Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - is important to recognize conditions that lead to injury, such as a wet floor leading to slips and falls … to lifting heavy linen bags
Explore using smaller linen bags
Attendant mops floor
Trips & Falls … Slips and falls on wet floor
Planned change to microfiber mop leaving floor drier than string mop … Attendant cleans & replaces step stools
Trips & Falls
Tripping and falling on stools
Step … Trips/falls
Explore options (other than blankets) to cover/secure cords
Check & replace oxygen
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www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-digital.html
May 01, 2024 - Using Integrated Social and Medical Risk Data Dashboards To Improve Chronic Disease Management and Prevention … Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall Assessment and Prevention … Lucero Organization: Brigham and Women’s Hospital Aims to develop a shareable, standards-based fall prevention … Impact and Sustainability of a Digitally-Based Diabetes Prevention Program (R01) PI: Yoshimi Fukuoka … The findings from this study have clear implications for primary care, where diabetes prevention is a
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlas3.html
March 01, 2013 - Socioecological model
Division of Cancer Prevention and Control, National Center for Chronic Disease … Prevention and Health Promotion. (2011). … 3, are also essential domains of measurement for understanding clinical-community relationships for prevention
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psnet.ahrq.gov/issue/he-thought-what-he-was-doing-was-good-people-why-it-so-difficult-prevent-unnecessary-medical
September 02, 2020 - Newspaper/Magazine Article
‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system?
Citation Text:
‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessa…
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psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use
December 24, 2008 - November 1, 2016
Preventing Falls With Injury.
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psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture
December 24, 2008 - January 2, 2017
Prevention Quality Indicators Overview.
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psnet.ahrq.gov/issue/improving-patient-safety-long-term-care-facilities-training-modules
August 17, 2022 - August 1, 2012
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care
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psnet.ahrq.gov/issue/challenge-competition-impact-patient-safety-tools
December 24, 2008 - Grant Recipient
Challenge Competition: Impact of Patient Safety Tools.
Citation Text:
Challenge Competition: Impact of Patient Safety Tools. Rockville, MD: Agency for Healthcare Research and Quality; 2023.
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psnet.ahrq.gov/issue/clinical-transformation-ascension-health-eliminating-all-preventable-injuries-and-deaths
January 05, 2017 - October 21, 2011
An inpatient fall prevention initiative in a tertiary care hospital.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Learning From Defects
Surgical Services
For: Cardiac … If this is the case, the CUSP team should investigate whether infection prevention strategies were in … The unit and the infection prevention team may detect that MRSA has been transmitted from one patient … A factor that falls in the category of being a minor reason for the defect and rarely occurs may not … No. 25-0029
April 2025
Learning From Defects
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AHRQ Safety Program for MRSA Prevention | Surgical