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2041. Facilitator Guide: Learning From Defects Through Sensemaking (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
      December 01, 2017 - Infection rates from hospital epidemiology and infection prevention also present known complications. … SAY: In the case of an elderly woman falling down in her hospital room, let’s list some factors that … The patient tries to get to the bathroom during the night and falls. … occurs rarely but has a singular impact on this particular defect, consider working on a factor that falls

2042. A strategic solution to preventing the harm associated with ambulance handover delays. | PSNet
      psnet.ahrq.gov/issue/strategic-solution-preventing-harm-associated-ambulance-handover-delays
      July 22, 2020 - Study A strategic solution to preventing the harm associated with ambulance handover delays. Citation Text: Evans C, Da’Costa A. A strategic solution to preventing the harm associated with ambulance handover delays. Emerg Nurse. 2024;32(6):32(6):15-20. doi:10.7748/en.2024.e2199. Copy C…

2043. Psi90 Factsheet Faq (pdf file)
      qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf
      August 31, 2016 -  PSI 08 (In-Hospital Fall with Hip Fracture Rate) now targets all hip fractures from inpatient falls

2044. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50844/psn-pdf
      January 29, 2020 - //psnet.ahrq.gov//#2 https://psnet.ahrq.gov//#2 https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery … Examples include patients who may be on medications that could increase their risk of falls or bleeding

2045. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33824/psn-pdf
      January 01, 2016 - This year, the Centers for Disease Control and Prevention (CDC) reported a 200% increase in opioid overdose … In this sense, the opioid epidemic is iatrogenic, and thus falls within the scope of patient safety.

2046. Improving the Delivery of Health Services at the Health Systems Level - Emerging Research | Digital Healthcare Research
      digital.ahrq.gov/2020-year-review/research-summary/improving-delivery-health-services-health-systems-level-emerging-research
      January 01, 2020 - nurse interactions at the bedside and their effect on nurse-sensitive patient outcomes such as patient falls … These include challenges related to prevention, such as containment strategies to prevent spread; preparation

2047. Update: Patient Engagement in Safety | PSNet
      psnet.ahrq.gov/perspective/update-patient-engagement-safety
      January 01, 2017 - While this intervention did not reduce safety incidents like pressure ulcers or falls , it did identify … March 13, 2024 Patient and caregiver perspectives on causes and prevention of ambulatory

2048. Patient Engagement in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-engagement-safety
      January 01, 2018 - experiences had no impact on a global measure of safety including outcomes like urinary tract infections and falls … March 13, 2024 Patient and caregiver perspectives on causes and prevention of ambulatory

2049. Use of Patient Buddy™ Application to Disseminate Knowledge & Prevent Readmission | Digital Healthcare Research
      digital.ahrq.gov/ahrq-funded-projects/use-patient-buddy-application-disseminate-knowledge-prevent-readmission
      January 01, 2023 - follows: To perform a pilot and feasibility study of disseminating current knowledge of readmission prevention … stakeholders (patients, caregivers, and nurse managers) towards improving the Patient Buddy App in the prevention

2050. Table 8G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8g.html
      February 01, 2023 -   Min s s s s s   Max 8,542 18,831 29,268 21,622 s Injurious Falls … 1,051 1,628 s   Max 12,315 10,606 s 11,115 13,261 11,132 11,243 Injurious Falls

2051. Table 8A: National HCBS Population | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8.html
      February 01, 2023 -   Min 1,506 s s s s   Max 6,772 17,194 10,853 27,397 s Injurious Falls … 1,473 1,015   Max 10,449 9,085 8,475 11,115 13,261 9,525 8,445 Injurious Falls

2052. Table 8E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8e.html
      February 01, 2023 -   Min s s s s s   Max 9,819 25,000 60,870 21,053 s Injurious Falls … 485 s   Max 13,223 10,425 7,934 16,685 41,237 12,441 11,765 Injurious Falls

2053. Table 8D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8d.html
      February 01, 2023 - 894   Min s s s s s   Max 3,665 6,218 6,218 13,974 s Injurious Falls … s 482 s   Max 4,720 3,827 3,566 11,374 25,641 4,261 4,038 Injurious Falls

2054. Table 8B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8b.html
      February 01, 2023 -   Min 1,663 s s s s   Max 7,916 20,000 16,970 11,285 s Injurious Falls … 1,625 918   Max 11,025 10,192 7,947 11,816 13,629 9,756 9,500 Injurious Falls

2055. Table 8F: HCBS Population Ages 18-64 Without Intellectual/Developmental Disabilities or Serious Mental Illness | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8f.html
      February 01, 2023 -   Min 1,710 s s s s   Max 19,029 26,952 26,016 40,816 s Injurious Falls … s s 2,151 s   Max 31,755 11,573 19,518 s s 19,248 23,318 Injurious Falls

2056. Table 8C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab8c.html
      February 01, 2023 -   Min s s s s s   Max 6,520 26,790 16,901 21,429 s Injurious Falls … s 785 s   Max 13,444 6,692 10,428 7,489 9,506 12,207 6,952 Injurious Falls

2057. Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. | PSNet
      psnet.ahrq.gov/issue/optimizing-therapy-prevent-avoidable-hospital-admissions-multimorbid-older-adults-operam
      December 21, 2022 - November 29, 2023 Evaluation of clinical practice guidelines on fall prevention and management … medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention

2058. Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial. | PSNet
      psnet.ahrq.gov/issue/effect-emergency-department-process-improvement-package-suicide-prevention-ed-safe-2-cluster
      March 09, 2022 - Study Effect of an emergency department process improvement package on suicide prevention … Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster … Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster … March 9, 2022 Evaluation of clinical practice guidelines on fall prevention and management … Related Resources Perspectives on Safety Suicide Prevention

2059. Patients' perspectives of diagnostic error: a qualitative study. | PSNet
      psnet.ahrq.gov/issue/patients-perspectives-diagnostic-error-qualitative-study
      February 10, 2012 - characterize their experiences with diagnostic errors and their perspectives on causes, impacts and prevention … February 10, 2012 Centers for Disease Control and Prevention Guideline for the Prevention … April 13, 2022 Fall prevention implementation strategies in use at 60 United States hospitals

2060. An intervention to decrease catheter-related bloodstream infections in the ICU. | PSNet
      psnet.ahrq.gov/issue/intervention-decrease-catheter-related-bloodstream-infections-icu
      June 16, 2011 - instituting five evidence-based preventive strategies recommended by the Centers for Disease Control and Prevention