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psnet.ahrq.gov/node/33721/psn-pdf
November 01, 2011 - Reducing falls and fall-related injuries in
the VA system. J Healthc Saf Q. 2003;1:25-33.
8.
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with
Thromboembolism.
November 16, 2022
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
The Case
A 61-year-old woman presented to …
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - probably tops this list, followed closely by missing a transient neurologic event that precipitates a fall
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www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
December 01, 2017 - operational event or situation that you would not want to happen again—an unsafe condition, a patient fall
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psnet.ahrq.gov/node/33879/psn-pdf
May 01, 2019 - have seen in the field and as an EMS physician (but also on the receiving end
of the EMS patient) fall … And that's
one thing that makes it really hard, because 1% of the patients they're going to see will fall
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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…
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psnet.ahrq.gov/node/851196/psn-pdf
July 05, 2023 - Patient falls while under supervision: trends from incident
reporting.
July 5, 2023
Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs.
2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508.
https://psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-…
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psnet.ahrq.gov/node/866280/psn-pdf
July 10, 2024 - Visitor restrictions during the COVID-19 pandemic and
increased falls with harm at a Canadian hospital: an
exploratory study.
July 10, 2024
Shennan S, Coyle N, Lockwood B, et al. Visitor restrictions during the COVID-19 pandemic and increased
falls with harm at a Canadian hospital: an exploratory study. J Patient …
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - A vision-based approach for fall detection using multiple cameras and convolutional neural networks: … a case study using the UP-Fall detection dataset.
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digital.ahrq.gov/sites/default/files/docs/medication-management-elderly-slides-081811.pdf
August 18, 2011 - 16%
Gastrointestinal 16%
Renal/electrolytes 12%
Fall … with injury 5%
Cardiovascular 4%
Fall
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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…
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psnet.ahrq.gov/node/38748/psn-pdf
April 19, 2011 - Utilization of the Seniors Falls Investigation Methodology
to identify system-wide causes of falls in community-
dwelling seniors.
April 19, 2011
Zecevic AA, Salmoni AW, Lewko JH, et al. Utilization of the Seniors Falls Investigation Methodology to
identify system-wide causes of falls in community-dwelling seniors…
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psnet.ahrq.gov/node/41112/psn-pdf
February 01, 2012 - Utilizing quality improvement methods to prevent falls
and injury from falls: enhancing resident safety in long-
term care.
February 1, 2012
MacLaurin A, McConnell H. Utilizing quality improvement methods to prevent falls and injury from falls:
enhancing resident safety in long-term care. J Safety Res. 2011;42(6):…
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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…
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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-…
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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…
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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…
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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.…
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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…
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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…