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301. AHRQ Webinar: Transforming Guidelines Into Action: Clinical Decision Support at the Point of Care - Q&As (pdf file)
     digital.ahrq.gov/sites/default/files/docs/transforming-guidelines-action-qas-06152023.pdf
     June 15, 2023 - Women’s Hospital Shareable, Interoperable Clinical Decision Support for Older Adults: Advancing Fall … What we found is that fall-risk increasing drugs (FRIDs), osteoporosis, and activity and mobility to … ANSWER: ASPIRE is available if the patient fails their fall risk screening. … QUESTION: Does ASPIRE have a long-term evaluation plan on the effectiveness of fall prevention? … ANSWER: Some of our patients complete the fall risk screening in the portal.

302. The tension between promoting mobility and preventing falls in the hospital. | PSNet
     psnet.ahrq.gov/issue/tension-between-promoting-mobility-and-preventing-falls-hospital
     April 24, 2018 - The authors suggest that immobilizing patients is not the answer to fall prevention and advocate for … November 12, 2014 Fall prevention implementation strategies in use at 60 United States … June 21, 2015 Inpatient fall prevention programs as a patient safety strategy: a systematic

303. Archived: Falls Prevention in Community-Dwelling Older Adults: Interventions | United States Preventive Services Taskforce
     www.uspreventiveservicestaskforce.org/uspstf/recommendation/falls-prevention-in-older-adults-interventions-2018
     April 17, 2018 - Studies found that exercise improved several fall-related outcomes. … Studies found reductions across several fall-related outcomes. … ) but not others (eg, number of persons experiencing a fall). … Falls and fall injuries among adults aged ≥65 years—United States, 2014. … Clinical preventive service recommendation: fall prevention in older adults. 2012.

304. Evaluation of AHRQ's On-time Pressure Ulcer Program - 2010 | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program/annual-summary/2010
     January 01, 2010 - Lessons learned from the PrU program will also serve to inform the development of an On-Time Fall Prevention … A yearlong process of workgroup meetings informed the standardization of fall documentation and the development … of tools to guide clinical decisionmaking for fall prevention. … program for reducing pressure ulcers. ( Ongoing ) Design the tools and establish the foundation for a fall … The draft fall prevention tools were reviewed with members of the Advisory Panel in September and October

305. The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. | PSNet
     psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-falls-children-physical-and
     September 14, 2022 - The SMAS was developed as an adjunct to the existing institutional fall prevention bundle and to address … Based on a fall risk assessment and the patient’s locomotion score (walk, wheelchair, crawl), they are … not require assistance After admission, all patients are placed on a red mobility alert until a fall

306. Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals. | PSNet
     psnet.ahrq.gov/issue/diet-order-entry-registered-dietitians-results-reduction-error-rates-and-time-delays-compared
     September 23, 2020 - Assessing the effectiveness of engaging patients and their families in the three-step fall … prevention process across modalities of an evidence-based fall prevention toolkit: an implementation … November 20, 2024 Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety … ): a patient-centered fall prevention toolkit.

307. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845360/psn-pdf
     March 29, 2023 - Prior to implementation, the fall rate was 4.9 per 1,000 admissions. … By December 2020, the fall rate was reduced to 0 falls per 1,000 admissions. … demonstrating-value-standardized-cognitive-assessment-tool-through-use-interprofessional https://psnet.ahrq.gov/web-mm/delirium-or-dementia https://psnet.ahrq.gov/web-mm/another-fall

308. 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

309. Medicare nonpayment, hospital falls, and unintended consequences. | PSNet
     psnet.ahrq.gov/issue/medicare-nonpayment-hospital-falls-and-unintended-consequences
     October 19, 2022 - May 13, 2021 Preventing falls and fall-related injuries in health care facilities. … March 20, 2013 Inpatient fall prevention programs as a patient safety strategy: a systematic

310. Patient falls in the operating room: why is this still a problem in 2024? | PSNet
     psnet.ahrq.gov/issue/patient-falls-operating-room-why-still-problem-2024
     May 08, 2024 - Patient falls are a never event; every fall should be reported and thoroughly investigated.

311. Impact of the unit-based patient safety officer. | PSNet
     psnet.ahrq.gov/issue/impact-unit-based-patient-safety-officer
     September 19, 2012 - The fall rate among inpatients decreased markedly after the patient safety officer position was begun … September 10, 2013 Inpatient fall prevention: use of in-room Webcams. … October 18, 2011 The cost of serious fall-related injuries at three midwestern hospitals

312. 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.

313. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34036/psn-pdf
     March 28, 2005 - (1) designing a falls prevention and management program; (2) effective interventions for high-risk fall … patients; (3) implementing hip protectors for high-risk fall patients; and (4) educating patients, … families, and staff on falls and fall-injury prevention.

314. 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.

315. 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.

316. 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.

317. Appropriate use of medical interpreters in the breast imaging clinic. | PSNet
     psnet.ahrq.gov/issue/appropriate-use-medical-interpreters-breast-imaging-clinic
     October 16, 2024 - Assessing the effectiveness of engaging patients and their families in the three-step fall … prevention process across modalities of an evidence-based fall prevention toolkit: an implementation … November 3, 2021 Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety) … : a patient-centered fall prevention toolkit.

318. Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds. | PSNet
     psnet.ahrq.gov/innovation/demonstrating-value-standardized-cognitive-assessment-tool-through-use-interprofessional
     December 02, 2020 - Prior to implementation, the fall rate was 4.9 per 1,000 admissions. … By December 2020, the fall rate was reduced to 0 falls per 1,000 admissions. … February 1, 2023 Fall prevention with the Smart Socks System reduces hospital fall rates

319. Interventions to Prevent Falls in Community-Dwelling Older Adults: USPSTF Recommendation Statement (pdf file)
     www.uspreventiveservicestaskforce.org/home/getfilebytoken/h-w99jVsodSL33kV2h2_qW
     April 17, 2018 - Studies found that exercise improved several fall-related out- comes. … Studies found reductions across sev- eral fall-related outcomes. … falls) but not others (eg, number of persons experiencing a fall). … Falls and fall injuries among adults aged �65 years—United States, 2014. … /clinical-recommendations/all/fall -prevention.html. 2012.

320. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/840172/psn-pdf
     November 16, 2022 - The SMAS was developed as an adjunct to the existing institutional fall prevention bundle and to address … Based on a fall risk assessment and the patient’s locomotion score (walk, wheelchair, crawl), they are … does not require assistance After admission, all patients are placed on a red mobility alert until a fall