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4041. Interventions-Horizon-Scan-High-Impact-1306 (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/interventions-horizon-scan-high-impact-1306.pdf
      June 01, 2013 - support rural primary care providers in developing knowledge about diseases that would typically fall … with the names of hospital and clinical staff to reduce risk of patient disorientation and delirium; fall … support rural primary care providers in developing knowledge about diseases that would typically fall … Eagle (CO): Western Eagle County Health Services District; 2011 Fall. 48 p. … Grand Forks (ND): Rural Assistance Center; 2010 Fall [accessed 2011 Oct 27]. [4 p].

4042. Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. | PSNet
      psnet.ahrq.gov/issue/preventing-patient-falls-systematic-approach-joint-commission-center-transforming-healthcare
      October 19, 2016 - Book/Report Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. Citation Text: Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project. Chicago, IL: Health Resea…

4043. Task Force Issues Draft Recommendation Statement on Vitamin D and Calcium to Prevent Falls and Fractures in Older Adults (pdf file)
      www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/vitamin-d-calcium-falls-bulletin.pdf
      January 21, 2025 - Task Force Issues Draft Recommendation Statement on Vitamin D and Calcium to Prevent Falls and Fractures in Older Adults 1 www.uspreventiveservicestaskforce.org Task Force Issues Draft Recommendation Statement on Vitamin D and Calcium to Prevent Falls and Fractures in Older Adults Vitamin D and calcium s…

4044. AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Enhancing Health Information Technology and Health Information Exchange (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-hit-hie-2025.pdf
      January 01, 2025 - ■ An AHRQ Patient Safety Learning Labiiiii (PSLL) developed an electronic Fall TIPS Tool to help patients … Key Findings/Impact: Investigators found that implementing the Fall TIPS toolkit reduced patient fall … into both the electronic and print versions, because patients are more likely to believe they need a fall … sites/default/files/2024-07/bates3-report.pdf https://www.ahrq.gov/patient-safety/settings/hospital/fall-tips … /index.html https://www.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html https://www.ahrq.gov

4045. A Sleep Promotion Toolkit for Hospitalized Patients - Final Report (pdf file)
      digital.ahrq.gov/sites/default/files/docs/citation/r21hs024330-ye-final-report-2018.pdf
      January 01, 2018 - A Sleep Promotion Toolkit for Hospitalized Patients - Final Report A Sleep Promotion Toolkit for Hospitalized Patients Principal Investigator: Lichuan Ye, PhD, RN Co-Investigator: Patricia C. Dykes, PhD, RN, FAAN, FACMI Grant No.: R21 HS24330 Project Period: 09/30/2015 - 09/29/2018 Or…

4046. Lessons in Safety Climate and Safety Practices from a California Hospital Consortium (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Singer.pdf
      April 01, 2003 - Lessons in Safety Climate and Safety Practices from a California Hospital Consortium 411 Lessons in Safety Climate and Safety Practices from a California Hospital Consortium Sara J. Singer, Kelly M. Dunham, Jennie D. Bowen, Jeffrey J. Geppert, David M. Gaba, Kathryn M. McDonald, Laurence C. Baker Abstract…

4047. Appendix B. Detailed Research Domain Framework Definitions and Classification Rules | Agency for Healthcare Research and Quality
      www.ahrq.gov/healthsystemsresearch/hspc-research-study/appendix-b.html
      June 01, 2020 - Non-HSR clinical trials that examine patient health outcomes (which would otherwise fall under Quality … care providers (e.g., doctors or medical residents), and therefore measures related to them do not fall

4048. Falling through the cracks: the invisible hospital cleaning workforce. | PSNet
      psnet.ahrq.gov/issue/falling-through-cracks-invisible-hospital-cleaning-workforce
      June 19, 2013 - Commentary Falling through the cracks: the invisible hospital cleaning workforce. Citation Text: Hacker CE, Debono D, Travaglia J, et al. Falling through the cracks: the invisible hospital cleaning workforce. J Health Organ Manag. 2022;36(8):981-986. doi:10.1108/jhom-02-2022-0035. Copy…

4049. Evidence Map on Home and Community Based Services (pdf file)
      effectivehealthcare.ahrq.gov/sites/default/files/related_files/evidence-map-hcbs-protocol.pdf
      July 27, 2023 - Evidence Map on Home and Community Based Services Evidence-based Practice Center Technical Brief Protocol Project Title: Evidence Map on Home and Community Based Services I. Background and Objectives One in four adults in the United States live with some form of disability that impacts their cognit…

4050. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33734/psn-pdf
      August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD August 1, 2012 In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd Editor's note: The topic of patient safety in long-term care facilities has not received the attent…

4051. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49615/psn-pdf
      December 01, 2010 - woman with mild dementia presented to the emergency department (ED) after sustaining a mechanical fall … What was their mobility and functional status prior to the fall, including any prior falls or hospitalizations

4052. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50647/psn-pdf
      November 06, 2019 - ‘Fear of falling’: how hospitals do even more harm by keeping patients in bed. November 6, 2019 Bailey M. Kaiser Health News. October 17, 2019. https://psnet.ahrq.gov/issue/fear-falling-how-hospitals-do-even-more-harm-keeping-patients-bed Patient falls with harm are a common sentinel event. This news story discuss…

4053. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837863/psn-pdf
      August 17, 2022 - The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide. August 17, 2022 Portland, OR: Oregon Patient Safety Commission; 2022.  https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide Patient falls are common sentinel events. The latest revis…

4054. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50862/psn-pdf
      February 05, 2020 - Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare. February 5, 2020 Sanghavi P, Pan S, Caudry D. Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare. Health Serv Res. 2020;55(2):201-210. doi:10.1111/1475-…

4055. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38715/psn-pdf
      February 17, 2011 - Medicare nonpayment, hospital falls, and unintended consequences. February 17, 2011 Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-3. doi:10.1056/NEJMp0900963. https://psnet.ahrq.gov/issue/medicare-nonpayment-hospital-falls-and-uni…

4056. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37792/psn-pdf
      February 15, 2011 - Exploring organizational context and structure as predictors of medication errors and patient falls. February 15, 2011 Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e3181695671.…

4057. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37518/psn-pdf
      March 13, 2008 - Innovation in patient safety: a new task design in reducing patient falls. March 13, 2008 Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5. https://psnet.ahrq.gov/issue/innovation-patient-safety…

4058. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40454/psn-pdf
      June 01, 2012 - Influence of unit-level staffing on medication errors and falls in military hospitals. June 1, 2012 Breckenridge-Sproat S, Johantgen M, Patrician PA. Influence of unit-level staffing on medication errors and falls in military hospitals. West J Nurs Res. 2012;34(4):455-74. doi:10.1177/0193945911407090. https://psne…

4059. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47508/psn-pdf
      October 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. October 24, 2018 Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372. https://psnet.ahrq.go…

4060. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39255/psn-pdf
      February 02, 2011 - The patient who falls: "It's always a trade-off." February 2, 2011 Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66. doi:10.1001/jama.2009.2024. https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade Through a case study, this article reviews evidence on risk…