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www.ahrq.gov/news/newsletters/e-newsletter/852.html
February 01, 2023 - Patient Falls Using an Evidence-Based Intervention May Reduce Costs
Implementing the AHRQ-funded Fall … TIPS Program , an evidence-based fall prevention intervention, was associated with $22 million in savings … Researchers analyzed electronic health record data for 900,635 patients to identify the costs of fall-related … They found that the average total cost of a fall is $62,521 and that the level of injury was not a significant … After implementation of the Fall TIPS intervention, there was a nearly 20 percent reduction in falls
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www.ahrq.gov/sites/default/files/2025-02/mcneil-report.pdf
January 01, 2025 - Final Progress Report: The National Quality Forum Fall Policy Conference 2008
The National Quality … Forum
Fall Policy Conference 2008
Principal Investigator: Dwight McNeil
Team Members: S. … Innovation in Patient Safety - National: National Coordination Council for Medication Error Reporting and Prevention … The
Council was formed to actively promote the reporting, understanding, and prevention of
medication … Division, US Pharmacopeia and Secretary, National Coordinating
Council for Medication Error Reporting and Prevention
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverviewmaterialspacket.pdf
October 16, 2017 - Abt Single-Sided Body Template
On-Time Falls Prevention: Overview Materials Packet
Samples of four … On-Time Falls Prevention Overview Materials Packet 1
O
n-Tim
e Falls P
revention: E
lectronic … Fall Date Date 10/4/13 1/16/14 2/11/14 2/27/14 3/6/14 4/17/14
Fall Day Day of week Saturday Thursday … Shift Shift N N D E N N
Fall Witnessed? Yes/no N N Y Y N N
If yes, who witnessed? … Yes/no Y Y Y N Y Y
PT Consult Date 10/4/13 1/16/14 2/11/14 3/6/14 4/17/14
On-Time Falls Prevention
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb30.html
December 01, 2017 - Fall Response
Chapter 3. Data Collection and Analysis Using TRIPS
Chapter 4. … _ →
___ Tighten the loose bolts and screws.
___ Replace the missing hardware.
___ Ask the Fall … Prevention Therapist to replace a wooden cane if it is cracked or weak.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/139-nv-hap-prevention-essential-one-pager.docx
October 01, 2024 - NV-HAP Prevention Essential Practices1-4
Practice routine oral care.4,5-8
Staphylococcus aureus is a … early mobilization.5,7,9
Conduct early mobilization, when possible, but it is important to consider fall … Healthcare- Associated Pneumonia (NV-HAP) Prevention: Essential Practices | 2
AHRQ Safety Program for … MRSA Prevention | ICU & Non-ICU Non-Ventilator Healthcare-Associated Pneumonia (NV-HAP) Prevention: … Non-ventilator health care-associated pneumonia (NV-HAP): Best practices for prevention of NV-HAP.
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www.ahrq.gov/patient-safety/news-events/psaw-2021/index.html
July 01, 2022 - Recent Releases
Fall TIPS: A Patient-Centered Fall Prevention Toolkit .
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
January 01, 2024 - Contributing Factors by Event Type Gen_5
Contributing Factors by Report Type Gen_6
Near Miss Prevention … Fall Other location 23,180 12.3%
Fall Outside area (i.e., grounds of this facility) 1,510 0.8%
Fall … Fall Supervisor/Support 130 0.1%
Fall Multiple 3,187 3.6%
Fall Other: Please specify 75,274 85.8% … Gen_7
Near Miss Prevention Actions within Event Types
Event Type Near Miss Prevention Action Event … 17.1%
Multiple Other: Please specify 22 10.4%
NOTE: Percentages shown are the percentage of near miss prevention
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html
December 01, 2017 - 24 hours after a fall. … Investigate Fall Circumstances
If fall circumstances are not investigated at the time of the incident … In other words, an intercepted fall is still a fall. … A fall without injury is still a fall. … Fall to floor (witnessed).
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www.ahrq.gov/research/findings/studies/index.html?page=360
January 01, 2024 - prevention toolkit. … The use of electronic decision support that tailors fall prevention strategy to patient-specific risk … factors, known as Fall T.I.P.S (Tailoring Interventions for Patient Safety), has proven to be an effective … A paper version of the Fall T.I.P.S toolkit was developed primarily for hospitals that do not have the … Iterative user centered design for development of a patient-centered fall prevention toolkit.
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www.ahrq.gov/hai/cusp/clabsi-final/clabsifinal1.html
January 01, 2013 - Based on this success, AHRQ contracted in fall 2008 with HRET to replicate this program nationally, starting … The contract was expanded in fall 2009 to include all 50 States, the District of Columbia, and Puerto … Many States used their regional HAI-prevention work groups developed as a result of the Centers for Disease … Control and Prevention (CDC) American Recovery and Reinvestment Act (ARRA) grants or other mechanisms … These included representatives from the State QIO, State health department, PSO, State infection prevention
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - The topic of this
package is fall prevention.
2. … Patient Fall Prevention and Management Protocol With Toileting Program
http://www.ihi.org/resources/ … a Safety Champion for Every Unit
Best Practice Intervention Packages for Fall Prevention
Braden Scale … Best Practice Intervention Packages for Fall Prevention
2. … Patient Fall Prevention and Management Protocol With Toileting Program
5.
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www.ahrq.gov/sites/default/files/wysiwyg/topics/IAWG-July-2024-meeting-notes.pdf
January 01, 2024 - of the National
Coordinator for Health Information Technology
CDC Centers for Disease Control and Prevention … DLS is working with the CDC Division
of Heart Disease and Stroke Prevention, the National Association … : Reducing Fall Risk for
Patients of All Age Groups … • Screening Patients for Fall Risk. … • Education for the Patient and Caregiver on Fall Prevention at
Home and in the Community.
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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
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www.ahrq.gov/hai/cusp/clabsi-hpwpreport/index.html
August 01, 2015 - High-Performance Work Practices in CLABSI Prevention Interventions
Next Page
Table of Contents … High-Performance Work Practices in CLABSI Prevention Interventions
Case Studies
Key Findings … Types of HAI Prevention Activities
Appendix 1. … Comparative qualitative research to explore the role of management practices in facilitating HAI prevention … Project Scan Findings
The project scan was completed in fall 2010.
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www.ahrq.gov/hai/pfp/hacrate2013-refs.html
October 01, 2015 - Implications for prevention. ADE Prevention Study Group. JAMA 1995;274:29-34. … Atlanta, GA: Centers for Disease Control and Prevention; March 2009. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Fall prevention in acute care hospitals: a randomized trial. JAMA 2010;304(17):1912-8. … VHA’s national falls collaborative and prevention programs.
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www.ahrq.gov/hai/pfp/interimhac2013-ref.html
December 01, 2014 - Implications for prevention. ADE Prevention Study Group. JAMA 1995;274:29-34. … Atlanta, GA: Centers for Disease Control and Prevention; March 2009. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Fall prevention in acute care hospitals: a randomized trial. JAMA 2010;304(17):1912-8. … VHA’s national falls collaborative and prevention programs.
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www.ahrq.gov/chain/practice-tools/practice-guidelines/updated-recommendations-for-glucocorticoid-induced-osteoporosis.html
March 01, 2017 - 2010 Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis
Grossman … American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced … Expansion of the discussion points relating to behavior modification, monitoring, and prevention counseling … to include: an assessment of fall risk; measurements of height and 25-hydroxyvitamin D; an evaluation … American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Aydin_2.pdf
January 01, 2021 - Fall prevention process variables
• Percent patients who fell assessed at risk for falling. … • Percent patients with fall prevention protocol in place at time of fall. … The report includes the graph shown, followed by a table listing
the actual numeric fall rates for each … and injury fall
incidence and rates. … In addition to the “report card” measures discussed above, CalNOC also provides detailed data
on fall
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2023.xlsx
January 01, 2023 - Contributing Factors by Event Type Gen_5
Contributing Factors by Report Type Gen_6
Near Miss Prevention … 85,574 0.6%
Fall Other 70,714 85,574 82.6%
Fall Human Factors 6,694 85,574 7.8%
Fall Mulitple 3,550 … 85,574 4.2%
Fall Environment 1,514 85,574 1.8%
Fall Supervisor/Support 149 85,574 0.2%
Fall Data … Gen_7
Near Miss Prevention Actions within Event Types
Event Type Near Miss Prevention Action Count … 22 202 10.9%
Multiple Unknown 34 202 16.8%
NOTE: Percentages shown are the percentage of near miss prevention
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Lapane.pdf
March 09, 2005 - oversedation), and 20 percent were falls.17 In long-term care
facilities, more than half of residents fall … The intervention was phased into 13 nursing homes in
the fall of 2003, with the full intervention start … Falls and
fall prevention in the nursing home. Clin Geriatr Med
1996 Nov;12(4):881–902.
25. … Fall injuries in the elderly. Clin
Geriatr Med 1985;1(3):501–12.
28. Monane M, Avorn J. … Causation,
correlation, and prevention. Clin Geriatr Med 1996;12
(4):847–58.
29.