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4001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60242/psn-pdf
      March 01, 2021 - that have been adopted by GRACE for 12 conditions, such as medication management, difficulty walking/falls … Given that outpatient visits for prevention and chronic care also increased, a broadly targeted program … A review of key quality indicators showed an improvement in falls, depression, medication management

4002. Final Progress Report: Evaluating e-Prescribing in a Community-Based, Integrated Health System (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/devine-report.pdf
      January 01, 2024 - Statins in the prevention of dementia and Alzheimer’s Disease: A Meta-Analysis.

4003. Crosscutting-Horizon-Scan-High-Impact-1312 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/crosscutting-horizon-scan-high-impact-1312.pdf
      December 01, 2013 - clinical staff in large print are used to lower risk of patient disorientation and delirium; fall-prevention … If the onus of improving patient adherence falls on the provider, staffing needs might increase because … calendars; boards with the names of hospital and clinical staff to reduce risk of patient delirium; fall prevention … at Mount Sinai Hospital (New York, NY), reported that “up to eight elderly patients a month were falling … experts thought these costs would be offset by reduced readmissions, reduced adverse events (e.g., falls

4004. Methodological Challenges in Describing Medication Dosing Errors in Children (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/McPhillips.pdf
      January 01, 2004 - potential errors difficult if not impossible, allowing for missed opportunities for future error prevention … Implications for prevention. ADE Prevention Study Group. JAMA 1995;274(1):29–34. 2. … Medication error prevention by clinical pharmacists in two children’s hospitals. … Effect of computerized physician order entry and a team intervention on prevention of serious medication … The impact of computerized physician order entry on medication error prevention.

4005. Interview with the OPTIMA Project Team | Agency for Healthcare Research and Quality
      www.ahrq.gov/evidencenow/projects/urinary/optima-interview.html
      November 01, 2024 - Recognizing that UI is highly stigmatized and the burden of initiating a UI conversation often falls

4006. Essentials of the Research Plan | Agency for Healthcare Research and Quality
      www.ahrq.gov/funding/process/grant-app-basics/esstplan.html
      January 01, 2017 - Essentials of the Research Plan A research plan is the main part of a grant application and describes a principal investigator's proposed research. This page describes the essential elements of a research plan. The research plan gives a principal investigator the opportunity to discuss proposed research, stat…

4007. Appendix E | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/environmental-scan-programs/envscan-program-ape.html
      April 01, 2018 - 26 429  -- Delirium 2 427  -- Nosocomial Infections 3 450  -- Patient Falls

4008. Instructions for Requesting Information | Agency for Healthcare Research and Quality
      www.ahrq.gov/policy/foia/instruct.html
      July 01, 2025 - and Families AHRQ - Agency for Healthcare Research and Quality CDC - Centers for Disease Control and Prevention

4009. AHRQ Final report: Designing for Patient Safety: Developing Methods to Integrate Patient Safety Concerns in the Design Process (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/joseph1-report.pdf
      January 01, 2024 - contribute to adverse patient safety outcomes like healthcare-associated infections, medication errors, and falls … including architecture, interior design, human factors, engineering, medicine, nursing, infection prevention … Attendees discussed the importance of collecting baseline data around key patient safety outcomes, such as falls … proverbial dilemma for patient safety, by Skip Gregory • Designing a healthcare setting with infection prevention

4010. Failure to Rescue the Mother | PSNet
      psnet.ahrq.gov/web-mm/failure-rescue-mother
      September 23, 2020 - Atlanta, GA: Centers for Disease Control and Prevention. [Available at] 2. … Recognition and Prevention Transfusion of 5 units of blood in the antepartum period. … Recognition and Prevention Patient had multiple risk factors for a significant hemorrhage; it is unclear … Recognition and Prevention Response Inadequate blood products were available. … Recognition and Prevention Readiness This project was funded under contract number 75Q80119C00004

4011. Physician-Reported Adverse Events and Medical Errors in Obstetrics and Gynecology (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-November_45.pdf
      January 01, 2007 - Procedure-related 11 11 Diagnosis 11 11 Other Poor communication 11 11 Miscellaneous 9 9 Prevention … reports into a computerized system in our existing hospital system, and these primarily relate to falls

4012. 4. Overlap and Coordination of Federal Agency Research Portfolios in HSR and PCR | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/overlap-and-coordination.html
      June 01, 2020 - The same federal research leader reported work on a diabetes prevention model that involved collaboration … with CDC “working hand-in-glove” utilizing not only CDC research expertise in diabetes prevention, but … also CDC’s prevention certification for providers and data collection. … Of particular concern were redundant priorities related to prevention practices and data systems for … For example, NIA and PCORI co-manage the big initiative on falls and NIA has done a number of planned

4013. Improving Communication and Teamwork in the Surgical Environment
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-slideset.pptx
      May 01, 2017 - Preventing Falls in Hospitals. January 2013. … Preventing Falls in Hospitals. January 2013.

4014. 2018 National Healthcare Quality and Disparities Report Data Sources (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2018qdr-datasources.pdf
      October 01, 2019 - References Centers for Disease Control and Prevention. … Center for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). … Center for Chronic Disease Prevention and Health Promotion. … of hospital-acquired infections; seven types of adverse events associated with procedures; patient falls … Adverse events associated with the hospital stay and not present on hospital admission (in-hospital falls

4015. A Pill Organizing Plight | PSNet
      psnet.ahrq.gov/web-mm/pill-organizing-plight
      June 19, 2018 - drug–disease interactions problematic for older adults, placing them at increased risk for delirium, falls … Yes/No Does the patient have a history of falls?

4016. Final Progress Report: Improving Medication Safety Across Clinical Settings (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/bates-report.pdf
      January 01, 2024 - Knowledge gained was pooled and compared to create a sharable information base of prevention strategies … The leading incident categories were labs (30%), followed by medication issues (17%), falls (11%), and … Project 3: Epidemiology and Prevention of Medical Errors in Psychiatric Inpatients Final Report … Furthermore, though some prevention strategies have been found to be effective in inpatients, the most … Prevention strategies should target the prescribing and monitoring stages of warfarin management.

4017. CHIPRA 119 Section 5, Literature Review and Discussion (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-119-section-5-lit-review.pdf
      March 19, 2012 - Health loss prevention in neonates. Journal of Perinatology, 28, 857-859. … normal range of 36.5° C to 37.5 °C (skin temperature of 0.5° C to 1.0° C lower) When skin temperature falls … bonnet may result in hyperthermia but only when metabolic heat production rises while skin temperature falls … When skin temperature falls to 35° C to 36° C, non-shivering thermogenesis is initiated (Bruck 1961) … Heat Loss Prevention (HeLP) Trial.

4018. Hiding in Plain Sight | PSNet
      psnet.ahrq.gov/web-mm/hiding-plain-sight
      April 24, 2019 - therapies.( 11 ) A live attenuated VZV vaccine was approved several years ago by the FDA for the prevention … reduced the burden of illness from HZ by 61.1% ( P PP3) Presently, the VZV vaccine is recommended for the prevention … Herpes zoster and postherpetic neuralgia: prevention and management. … April 24, 2019 An inpatient fall prevention initiative in a tertiary care hospital.

4019. Dementia-Nursing-Home-Characteristics Executive (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/dementia-nursing-home-characteristics_executive.pdf
      October 01, 2012 - skin ulcers; decline in functioning, self-care, or maintenance; decline in cognitive functioning; falls … special care unit; SOE = strength of evidence; vs. = versus Note: No study examined the outcome of falls … No studies examined the outcome of falls (insufficient SOE). KQ 2. … special care unit; SOE = strength of evidence; vs. = versus Note: No study examined the outcomes of falls … As noted, no evidence surfaced on falls or on several aspects of psychosocial well-being, including

4020. In Conversation With… David Juurlink, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
      May 22, 2017 - Delirium, falls, fractures, subdurals, testosterone suppression, motor vehicle collisions. … Atlanta, GA: Centers for Disease Control and Prevention, National Center for Health Statistics, National … Atlanta, GA: Centers for Disease Control and Prevention. Available at [ Available at ] 8. … opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention … opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention