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81. A Model of Care Delivery to Reduce Falls in a Major Cancer Center (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kline_32.pdf
    March 03, 2008 - • Procedure within 48 hours of fall (Y/N). • Use of assistive devices (Y/N). … • Did the patient call for help prior to the fall? … • Were family members or visitors present at the time of the fall? … Notify receiving areas of high fall risk, e.g., radiology. 10. … An assisted fall occurs when a patient is being accompanied by a care provider and begins to fall, typically

82. Network of Patient Safety Databases Chartbook, 2019 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2019.pdf
    January 01, 2019 - FALL The Fall event type in CFER-H V1.2 collects reports of Incidents involving a fall. … another patient) or a near fall (i.e., loss of balance that does not result in a fall). … Fall Assistance 81.4% 18.6% Fall considered unassisted Fall known to be assisted Note: The CFER-H … another patient) or a near fall (i.e., loss of balance that does not result in a fall). … type of physical injury sustained in the fall as TYPE OF INJURY AS RESULT OF FALL.

83. Hospital Resources | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/about.html
    December 01, 2017 - Fall Prevention in Hospitals Training Program AHRQ developed the Fall Prevention in Hospitals Training … and learn how to overcome the challenges associated with developing, implementing, and sustaining a fall … Falls in Hospitals Each year, somewhere between 700,000 and 1,000,000 people in the United States fall … Fall prevention involves managing a patient's underlying fall risk factors and optimizing the hospital's … toolkit focuses on overcoming the challenges associated with developing, implementing, and sustaining a fall

84. Appendix C8: Fall Interventions Plan Sample | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/apcfigtxt8.html
    December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix C8: Fall … Fall Response Chapter 3. Data Collection and Analysis Using TRIPS Chapter 4.

85. Final Progress Report: Safety Outcomes of Obese Residents in US Nursing Homes (pdf file)
    www.ahrq.gov/sites/default/files/2024-05/felix-report.pdf
    January 01, 2024 - Overall, 21.1% of residents experienced a fall. … Overall, 6.9% of residents experienced a fall with an injury. … who were class 3 obese were 34.2% less likely to fall (SE=0.01, p<0.001). … 19.9% less likely to fall (SE=0.01, p<0.000). … Being underweight increased the odds of experiencing a fall, fall with injury, or pressure ulcer but

86. Abt Single-Sided Body Template (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverviewmaterialspacket.pdf
    June 02, 2025 - Fall Date Date 10/4/13 1/16/14 2/11/14 2/27/14 3/6/14 4/17/14 Fall Day Day of week Saturday Thursday … Tuesday Thursday Thursday Thursday Fall Time Time or “not known” 6:35 a.m. 5:35 a.m. 7:15 a.m. 6:50 … Shift Shift N N D E N N Fall Witnessed? Yes/no N N Y Y N N If yes, who witnessed? … Location Fall location: room; bathroom; hallway; dining room; activities; therapy; beauty parlor; … Walking Walking Toileting Toileting Potential Causes of Fall Unknown Behavior – agitation

87. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/highrisk.html
    October 01, 2017 -     Mental: Unsafe Behaviors Mental: Cognitive Impairment Gait and Balance Instability Fall … : 8-30 Days Fall: 31-180 Days Psychoactive Medications Other High-Risk Medications Resident … Status Change Behavior: New Unsafe New Gait/ Balance or Device Order New Fall

88. Sampleransferandintakenotes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/sampleransferandintakenotes.pdf
    June 02, 2025 - neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound and skin, fall-related … and non-fall-related injury, musculoskeletal, other changes not specified elsewhere, or treatment not … diabetes Wound & Skin  Cellulitis  Edema  Infected wound or decubitus  Jaundice  Rash Fall-Related … Injury  Major injury  Minor injury Non-Fall-Related Injury  Major injury  Minor injury Musculoskeletal … Dehydration  Dementia  Depression  Diabetes  Dysrhythmias  Electrolyte imbalance  Fever  Fall

89. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits - Transfer Note and Intake Note (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.pdf
    June 02, 2025 - neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound and skin, fall-related … and non-fall-related injury, musculoskeletal, other changes not specified elsewhere, or treatment not … diabetes Wound & Skin  Cellulitis  Edema  Infected wound or decubitus  Jaundice  Rash Fall-Related … Injury  Major injury  Minor injury Non-Fall-Related Injury  Major injury  Minor injury Musculoskeletal … Dehydration  Dementia  Depression  Diabetes  Dysrhythmias  Electrolyte imbalance  Fever  Fall

90. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/steps.html
    October 01, 2017 - Step 4: Introduce On-Time Fall Prevention The On-Time Facilitator provides technical assistance via … Step 15: Review Fall Incidence The Facilitator works with the team to generate QI monitoring reports … that identify fall rates to provide feedback to the Change Team and support reporting requirements. … Agree to Use On-Time Fall Prevention   2. … Review Fall Incidence As required 16.

91. Implementing Opioid Risk Screening for Older Adults Using Automated Patient Reminders in an Electronic Health Record Case Study (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-risk-screening.pdf
    June 02, 2025 - improvement (QI) lead at Pearl Family Medicine, recognized the need to implement an opioid misuse and fall-risk … screeners linked to the annual wellness visits of older adults on LTOT: the STEADI tool for assessing fall … patients (60+): 30% 1 MD = Medical Doctor; PA = Physician Assistant. 2 The STEADI algorithm for fall … implementation progress, the Pearl team selected rates of older adults with opioid-related risk/ fall … ▶ Stopping Elderly Accidents, Deaths & Injuries (STEADI) tool for assessing fall risk.

92. Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-11-root-cause-analysis.pdf
    December 27, 2021 - Conduct a fall-out analysis to determine why individuals did not receive an indicated service. … A third process you can use with your practices to identify root causes is fall- out analysis. … Steps for Completing a Fall-Out Analysis 1. … Identify two-to-five patient cases that “fall out” of the performance metric in question. 2. … Example: Using fall-out analysis to improve diabetes care in a federally qualified health center.

93. Appendix B2: Tracking Record for Improving Patient Safety TRIPS (Text Description) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb2txt.html
    December 01, 2017 - Fall Response Chapter 3. Data Collection and Analysis Using TRIPS Chapter 4. … ___________________ Section B Was the incident: __ Found on the floor (unwitnessed) __ Fall … to the floor (witnessed) __ Near fall (patient lowered to floor by staff/other or stabilized) __ … Self-reported fall The cause of the incident was: __ Lost balance __ Slipped (specify): __ … Other site (specify): Was this person in the Falls Management Program at the time of the fall

94. Impact of AHRQ’s Patient Safety Tools: Challenge Competition | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/about/challenge-competition.html
    February 01, 2024 - for Improving Quality of Care was instrumental in guiding the creation of an initiative entitled "Fall … Initially focused on two medical-telemetry units and eventually expanding to include additional units, fall … The "Fall Free Friday" activities resulted in a 31% decrease in acute care falls from 4th quarter 2022

95. NPSD Dashboards | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/index.html
    September 01, 2024 - Falls Dashboard Details the extent of harm due to falls, the presence of fall assistance, presence of … fall assistance by patient harm, type of fall injury, and fall location.      

96. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereport-handouts.html
    June 01, 2017 - neurological/psychological, gastrointestinal/genitourinary, endocrine/nutritional/metabolic, wound and skin, fall-related … and non-fall-related injury, musculoskeletal, other changes not specified elsewhere, or treatment not … Cellulitis |___| Edema |___| Infected wound or decubitus |___| Jaundice |___| Rash Fall-Related … Injury |___| Major injury |___| Minor injury Non-Fall-Related Injury |___| Major injury … |___| Diabetes |___| Dysrhythmias |___| Electrolyte imbalance |___| Fever |___| Fall

97. Final Progress Report: Care Interventions and Quality of Care in Rural and Urban Nursing Units (pdf file)
    www.ahrq.gov/sites/default/files/2024-04/baernholdt-report.pdf
    January 01, 2024 - the relationships between contextual factors, care interventions, and pressure ulcer rates (PUR) and fall … widespread implementation of preventive care interventions, national pressure ulcer rates (PUR) and fall … Prior fall risk assessment. 2. … Fall rates in urban and rural nursing units. Does location matter? … A National Comparison of Rural/Urban Pressure Ulcer and Fall Rates.

98. Appendix B8: Unsafe Behavior Worksheet (Text Description) | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb5txt.html
    December 01, 2017 - Fall Response Chapter 3. Data Collection and Analysis Using TRIPS Chapter 4. … Record the date of any fall that occurs after entry. … Resident Name Date entered into FMP Fall Dates Notes                     … Suggestions for further assessment and/or interventions ( ) Medications that could increase fall … Return to Document   Fall Interventions Plan (Text Description) Resident: ____________________

99. Appendix B26: Reducing Falls: A Safety Checklist for the Home | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb26.html
    December 01, 2017 - Fall Response Chapter 3. Data Collection and Analysis Using TRIPS Chapter 4. … One in three people 65 years and older fall every year and most of these falls happen in the home. … References: The Fall Prevention Project , Southeast Senior Housing Initiative, Baltimore, MD, 1997

100. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/assess.html
     November 01, 2017 - The team is expected to use the Self-Assessment Worksheet to help understand current fall prevention … changes in care plans, and Carry out investigations, including root cause analysis, when an injurious fall