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81. 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

82. 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.

83. 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.

84. 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.

85. 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

86. 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

87. 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.

88. 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

89. 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: ____________________

90. 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

91. Resources by Safety Topic | Agency for Healthcare Research and Quality
    www.ahrq.gov/action-alliance/resources/type-harm.html
    September 01, 2025 - on falls reduction using quality improvement tactics to assist nursing facilities in improving their fall … AHRQ Fall Tailoring Interventions for Patient Safety (TIPS): A Patient-Centered Fall Prevention Toolkit … Organizations can use this report to understand fall prevention strategies. … and Prevention (CDC) Stopping Elderly Accidents, Deaths & Injuries (STEADI) Initiative: Older Adult Fall … Toolkit elements include a program self-assessment, falls notebook, post-fall huddle documents, and more

92. Appendix B25: Ways Families Can Help Reduce Fall Risk | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb8.html
    December 01, 2017 - Quality Improvement Initiative for Nursing Facilities Appendix B25: Ways Families Can Help Reduce Fall … Fall Response Chapter 3. Data Collection and Analysis Using TRIPS Chapter 4.

93. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
    January 01, 2022 - Within a given AE, such as a fall, abstractors are instructed to only report the highest severity AE … , such as the most severe fall. … 124 22678 0.5 0.5 – 0.7 Unassisted Fall 105 22678 0.5 0.4 – 0.6 Assisted Fall 19 22678 0.1 0.1 – … 132 26291 0.5 0.4 – 0.6 Unassisted Fall 117 26291 0.5 0.4 – 0.5 Assisted Fall 15 26291 0.1 0.0 – … Fall Assisted Fall Unassisted Fall 5.

94. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
    January 01, 2022 - Within a given AE, such as a fall, abstractors are instructed to only report the highest severity AE … , such as the most severe fall. … 124 22678 0.5 0.5 – 0.7 Unassisted Fall 105 22678 0.5 0.4 – 0.6 Assisted Fall 19 22678 0.1 0.1 – … 132 26291 0.5 0.4 – 0.6 Unassisted Fall 117 26291 0.5 0.4 – 0.5 Assisted Fall 15 26291 0.1 0.0 – … Fall Assisted Fall Unassisted Fall 5.

95. Final Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
    January 01, 2025 - Domains of Patient Safety Population (Fall, UTI) Process or Outcome Measures Fall Fall Process … )62 Fall Fall Outcome Repeat fall within 30 days of index ED visit (uses our previously published definitions … Impact of fall prevention on nurses and care of fall risk patients. … Development and implementation of a pharmacy fall prevention program. … Tool 3I: Medication Fall Risk Score and Evaluation Tools.

96. Appendix B3: Fax Alert | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/fax.html
    February 01, 2023 - Fall Response Chapter 3. Data Collection and Analysis Using TRIPS Chapter 4. … It is this resident's ______ fall in the past 180 days.

97. 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

98. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention - Facilitator Training: Overview of On-Time (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverview-ig.pdf
    June 02, 2025 - staff generally do a good job of investigating and following up after an adverse event, such as a fall …  It is more difficult for staff to identify which residents are at risk for a fall or pressure … we be sure to instruct the nursing assistant to stay close by when she was ambulating to prevent a fall …  Identify resident risk factors that may have caused a fall. … o Postfall Assessment Summary Report identifies the circumstances and context of a fall and provides

99. New Tools Help Health Providers Reduce Patients' Risk of Falls | Agency for Healthcare Research and Quality
    www.ahrq.gov/patients-consumers/patient-involvement/patients-risk-of-falls.html
    September 01, 2015 - Overview Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care Using a Computerized Fall

100. Appendix B14: Pre and Posttests for Inservice #2, How to Reduce Falls | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manap14.html
     December 01, 2017 - Fall Response Chapter 3. Data Collection and Analysis Using TRIPS Chapter 4. … A resident who leans over or slides down while seated in a wheelchair is more likely to fall out of the