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281. Implementing Opioid Risk Screening for Older Adults Using Automated Patient Reminders in an Electronic Health Record Case Study (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-risk-screening.pdf
     December 15, 2023 - screenings: the Stopping Elderly Accidents, Deaths & Injuries (STEADI2) tool for assessing risk of falls

282. Fallpxtool3D (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3d.docx
     January 29, 2013 - Reference: Falls prevention strategies in health care settings.

283. Appendix B31: Engineer Wheelchair Inspection | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb31.html
     December 01, 2017 - Patient Safety News and Events Education & Training Resources The Falls … B31: Engineer Wheelchair Inspection Previous Page Next Page Table of Contents The Falls … Falls Engineer Instructions Resident Name: ______________________   Room: ___________

284. What Is Patient Safety Culture? | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/sops/about/patient-safety-culture.html
     March 01, 2022 - Hospital units with more positive SOPS scores had: Fewer hospital-acquired pressure ulcers and patient falls … Medicare & Medicaid Services (CMS) Nursing Home Five-Star Quality ratings. 5 Lower risks of resident falls

285. Saving Lives and Saving Money: Hospital-Acquired Conditions Update | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/2014-final.html
     January 01, 2018 - CLABSIs MPSMS (2014) Blood Stream Infections Associated With Central Venous Catheters 5,000 0.2 Falls … MPSMS (2014) In-Hospital Patient Falls 260,000 7.9 Obstetric Adverse Events PSI (2014) … Bloodstream Infections 18,000 5,000 13,000 72% $221,000,000 2,405 Falls … 50% 50% 25% 10,000 $17,000 .185 $170,000,000 1,850 Falls … 1,040,500 NA NA $9,141,150,000 35,647 * Additional costs per HAC for Falls

286. Appendix | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/interimhac2013-ap1.html
     December 01, 2014 - MPSMS (2013) Blood Stream Infections Associated With Central Venous Catheters 9,200 0.28 Falls … MPSMS (2013) In-Hospital Patient Falls 240,000 7.2 Obstetric Adverse Events PSI (2012)

287. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/hacrate2011-12.html
     January 01, 2018 - Blood Stream Infections Associated With Central Venous Catheters 17,000 0.52 17,000 0.51 Falls … MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse Events PSI

288. Creating a Work-Around to Implement Fall Risk Screening For Older Adults Using Appointment Notes Case Study (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-work-around.pdf
     December 15, 2023 - Creating a Work-Around to Implement Fall Risk Screening For Older Adults Using Appointment Notes Case Study Focus on High Leverage Change: Risk Assessment Creating a Work-Aro…

289. Generic Dashboard Data 2023 (xls file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2023.xlsx
     January 01, 2023 - Introduction Introduction-Generic Patient Safety Concern The tables in this workbook present generic data on Patient Safety Concerns submitted by AHRQ-listed Patient Safety Organizations (PSOs) to the Network of Patient Safety Databases (NPSD) through December 31, 2022. The tables include distributions of events and…

290. Using an Anonymous Web-Based Incident Reporting Tool to Embed the Principles of a High-Reliability Organization (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Conlon_50.pdf
     May 06, 2008 - PEERs data have also been instrumental in the development of programs for falls risk assessment and … These changes increase the reliability of the organization and prevent patients from falling through … PEERs data reveal that many inpatient falls occur when patients get out of bed to use the bathroom. … Data from falls are routinely collected and used in an ongoing effort to reduce the number of patient … falls.

291. CHIPRA 201: Section 5, Table 3 (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-201-asthma-section-5-table-3.pdf
     February 19, 2016 - After training, inhaler technique falls off with time, so checking and re- training must be repeated

292. Using an EHR System to Prevent Opioid Use Disorder in Older Adults in Primary Care Practices Case Study (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-ehr-oud.pdf
     December 18, 2023 - for evaluating effectiveness and potential adverse effects of opioid use in older adults: misuse, falls … control level ■ adverse events experienced ■ activity level ■ aberrant behaviors ■ cognition ■ falls

293. Fallpxtool2F (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool2f.docx
     November 16, 2011 - 2F: Action Plan Background: The purpose of this tool is to provide a framework for outlining steps that will be needed to design and implement the fall prevention initiative. Reference: Adapted from material produced by MassPro, a participant in the Centers for Medicare & Medicaid Services Quality Improvement Organiz…

294. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013 | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/hai/pfp/interimhac2013-ap4.html
     December 01, 2014 - Bloodstream Infections 40,000 50% 50% 25% 10,000 $17,000 .185 $170,000,000 1,850 Falls … 44.1% 39.3% 17.4% 1,040,500 NA NA $9,141,150,000 35,647 * Additional costs per HAC for Falls

295. Planning and Implementing the Patient Advocacy Reporting System in the Sanford Health System | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/pichert.html
     August 01, 2017 - Sanford Health Medical Center Sites in the North (Fargo, Bismarck) and South (Sioux Falls, Bemidji) Regions … Hoffman, MD, FACP, at the time of the planning project: Patient Safety Officer, Sanford Health, Sioux Falls … Region, Sioux Falls, SD. … the planning project, Senior Vice President, Clinical Risk Management, Sanford Health System, Sioux Falls … Leadership Development & Physician Well Being, Sanford PARS Medical Director, Sanford Health, Sioux Falls

296. Transcript-Speaking-Up (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/transcript-speaking-up.doc
     May 01, 2017 - undergoing a laparoscopic cholecystectomy, and the surgeon notices that the patient’s blood pressure is falling

297. Assessing the Impact of Value-Based Purchasing Programs | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-waters.html
     February 01, 2022 - catheter-associated urinary tract infections (CAUTI), central-line bloodstream infections, (CLABSI) falls … change dropped by 11 percent for CAUTI and 10 percent for CLABSI but remained essentially the same for falls

298. Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-11-root-cause-analysis.pdf
     December 27, 2021 - analysis will require input from a clinician, as many of the factors that contribute to a patient’s falling … these patients’ medical records and other related documents to identify potential causes for their falling

299. Appendix C. Sample Search Strategies | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/engage/appc.html
     March 01, 2017 - Control [ti]) OR handwashing OR (hand [ti] AND (hygiene [ti] OR disinfection [ti] OR wash [ti]))) OR (Accidental … Falls [mh] OR (fall* [ti] AND (preventing [ab] OR prevention [ab] OR reducing [ab] OR reduction [ab]

300. Job Aid: Standardized Quality Measures (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-standardized-quality-measures.pdf
     January 07, 2022 - Job Aid: Standardized Quality Measures Primary Care Practice Facilitator Training Series 1 Job Aid: Standardized Quality Measures Familiarity with the standardized quality measures that payers and regulatory groups use is an important part of a practice facilitator's core knowledge. Standar…