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Showing results for "fall prevention".
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1. Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
   January 01, 2019 - changes in mental status • Cascade with oversedation while on multiple opioid medications leading to a fall … thromboembolisms, deep vein thrombosis, or pulmonary embolisms • Acute pulmonary embolus with inadequate prevention … patient resulting in desaturation, hypoxemia, replacement of the tube, and aspiration pneumonia Fall … with injury • Fall with recurrent right hip fracture associated with inadequate monitoring Page 5 … with injury • Fall with laceration forehead • Fall with soft tissue hematoma over left maxillary sinus

2. Artificial Intelligence (AI) in Healthcare Safety Program: October 2024 Update (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
   July 01, 2025 - For example, a key finding of the most recent Spotlight, on Patterns of Fall Interventions,13 is that … were in place among patients with different risks for falls, suggesting a less tailored approach to fall … prevention than what might be expected. … VHA) National Center for Patient Safety (NCPS) has a primary goal of, “the nationwide reduction and prevention … Like the PSP, NCPS takes a systems approach to patient safety, focusing on prevention.

3. AHRQ Slide Template 2019-Widescreen (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
   January 01, 2020 - Acuity, Size, IRF/IRU Quarterly conference calls/Safe Tables • General webinar and Infection Prevention … Writing an Infection Control Plan for Joint Commission Survey • Durability of Outcomes/Readmission Prevention

4. Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in OIG Report as Clearly Preventable or Likely Preventable by Clinical Category (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
   July 01, 2016 - event • Skin tear with fungal infection that developed under brace • Skin excoriation on buttocks Fall … associated with patient care • Fall from bed with minor injuries (elbow, knees, and small skin tear

5. Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/strategies-to-improve-patient-safety_draft-report.pdf
   December 21, 2021 - Falls Dashboard The Falls Dashboard details the extent of harm due to falls, the presence of fall … assistance, the presence of fall assistance by patient harm, the type of fall injury, and fall location … Advances in the Prevention and Control of HAIs. … The contract was expanded in fall 2009 to offer participation to all 50 States, the District of Columbia … Advances in the Prevention and Control of HAIs.

6. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/npsdpatient-safety-culture-brief.pdf
   September 01, 2016 - Table events: ■ Failure to inform patients of abnormal test results ■ Factors related to falls ■ Prevention