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psnet.ahrq.gov/issue/mobile-situ-obstetric-emergency-simulation-and-teamwork-training-improve-maternal-fetal
July 09, 2008 - Study
Mobile in situ obstetric emergency simulation and teamwork training to improve maternal–fetal safety in hospitals.
Citation Text:
Guise J-M, Lowe NK, Deering S, et al. Mobile in situ obstetric emergency simulation and teamwork training to improve maternal-fetal safety in hospitals.…
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psnet.ahrq.gov/issue/test-result-communication-primary-care-clinical-and-office-staff-perspectives
November 20, 2015 - June 26, 2019
Evaluation of clinical practice guidelines on fall prevention and management
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psnet.ahrq.gov/issue/they-say-they-listen-do-they-really-listen-qualitative-study-hospital-doctors-experiences
November 29, 2017 - Study
"They say they listen. But do they really listen?": A qualitative study of hospital doctors' experiences of organisational deafness, disconnect and denial.
Citation Text:
Creese J, Byrne JP, Conway E, et al. “They say they listen. But do they really listen?”: A qualitative study of…
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psnet.ahrq.gov/issue/are-opioid-infusions-used-inappropriately-end-life-results-qualitysafety-project
November 16, 2022 - Related Resources
Patient Safety Innovations
Suicide Prevention
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psnet.ahrq.gov/issue/association-between-physician-depressive-symptoms-and-medical-errors-systematic-review-and
January 12, 2022 - October 23, 2019
Evaluation of clinical practice guidelines on fall prevention and management
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psnet.ahrq.gov/issue/impact-medication-reconciliation-improving-transitions-care
June 19, 2019 - January 25, 2023
View More
Related Resources
Prevention of perioperative
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/diverticulitis-one-page.docx
November 01, 2019 - relevant multi-specialty consultation, including infectious diseases, should be considered for cases falling
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psnet.ahrq.gov/issue/no-harm-found-when-nurse-anesthetists-work-without-supervision-physicians
August 04, 2021 - Study
No harm found when nurse anesthetists work without supervision by physicians.
Citation Text:
Dulisse B, Cromwell J. No harm found when nurse anesthetists work without supervision by physicians. Health Aff (Millwood). 2010;29(8):1469-1475. doi:10.1377/hlthaff.2008.0966.
Copy Citat…
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psnet.ahrq.gov/issue/how-prevalent-are-hazardous-attitudes-among-orthopaedic-surgeons
March 14, 2018 - December 16, 2015
Evaluation of clinical practice guidelines on fall prevention and management
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - Accountability in Patient Safety
January 1, 2015
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/accountability-patient-safety
Annual Perspective 2015
The tension between the no-blame culture espoused in the early years of the safety movement and …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/business_case-slides/The-Business-Case-for-CUSP-Jan-17-2012-508.ppt
January 01, 2012 - “An ounce of prevention
is worth a pound
of cure.”
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv.html
June 01, 2010 - Serious Reportable Events
Measure
Source
Notes
Falls with injury
American Nurses … Avoidable Hospitalizations
Measure
Source
Notes
Prevention Quality Indicators: set
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www.ahrq.gov/news/events/nac/2015-03-nac/nacmtg0715-minutes.html
December 01, 2015 - Rothwell, M.B.A., M.S., National Center for Health Statistics, Centers for Disease Control and Prevention … The program will feature the ABCs of cardiovascular prevention. … The agency will fund studies to address a broad range of issues, including pressure ulcers and falls … We have made great advances in health, yet need greater prevention of many conditions. … The Surgeon General's office is interested in creating a culture of prevention.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-rev-0724update.pdf
July 01, 2024 - ■ Reduce patient harms and errors within hospital settings (e.g., falls, adverse drug interactions, … both the electronic and print versions, because patients are more likely to believe they
need a fall prevention … plan and then follow that plan if they know their risks of harm for
falling. … from prospective medication monitoring care plans when complex medication
regimens carry risks for falls
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psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - The Case
A 49-year-old previously healthy man presented to the emergency department (ED) after falling … Necrotizing fasciitis caused by Vibrio vulnificus: epidemiology,
clinical findings, treatment and prevention
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www.uspreventiveservicestaskforce.org/uspstf/recommendation/dementia-older-adults-screening-1996
January 01, 1996 - wandering, incontinence, adverse drug reactions, poor personal hygiene, and unintentional injuries (falls … Patients are at increased risk of falls and automobile accidents as dementia progresses. 63 Effective … interventions to prevent falls or accidents in patients with dementia have not been determined, however
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/handouts.html
September 01, 2017 - Program Manager: Let’s move on to the second part of the Self-Assessment, the prevention plan. … Tell me about the meetings that you have where hospital transfer prevention is discussed. … But that’s not prevention.
Facilitator: Who is at the morning meeting? … But, same as Mary said, that’s not about prevention. … Are there any other meetings where transfers or transfer prevention is discussed?
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/109-performing-premortem-project-assessment-fg.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Mini Presentation:
Performing a Premortem Project … telescope that could look into the future and let you see what is going to happen with your MRSA and SSI prevention … No. 25-0029
April 2025
Premortem
Assessment Tool
| 1
AHRQ Safety Program for MRSA Prevention | Surgical
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Reducing falls and fall-related injuries in the VA system. J Healthc Saf Q. 2003;1:25-33.
8. … Related Resources From the Same Author(s)
Root cause analysis of reported patient falls … January 1, 2015
Perspective
How Does Infection Prevention … February 1, 2014
Perspective
Implementing a Fall Prevention
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www.uspreventiveservicestaskforce.org/uspstf/document/evidence-summary/osteoporosis-screening-2002
September 17, 2002 - risk factors, such as psychomotor impairment, poor gait, and other factors that increase the risk for falling … effect on hip fracture rates among women 80 years of age or older who had one or more risk factors for falls … Consensus statement on prevention and treatment of osteoporosis. … Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. … I
Good: bisphosphonate trials indicate fracture prevention.