-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13.html
December 01, 2012 - Pressure Ulcer
4,010
3,925
2,853
4,175
3,854
2,547
2,961
4,271
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13c.html
December 01, 2012 - Pressure Ulcer
3,031
3,001
1,416
3,073
2,914
1,211
1,591
3,369
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13d.html
December 01, 2012 - Pressure Ulcer
1,490
1,499
1,251
1,746
1,431
1,216
1,326
1,488
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13f.html
December 01, 2012 - Pressure Ulcer
6,180
6,029
3,239
5,537
6,191
3,067
3,636
6,965
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13g.html
December 01, 2012 - Pressure Ulcer
4,497
4,649
3,696
5,077
4,632
2,818
3,647
5,097
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13b.html
December 01, 2012 - Pressure Ulcer
4,306
4,221
3,413
4,523
4,155
3,058
3,454
4,564
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab13e.html
December 01, 2012 - Pressure Ulcer
3,490
2,892
2,126
3,314
2,623
2,679
2,298
3,287
Injurious Falls
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-factraining-guide.docx
June 02, 2025 - or EMR, data to make staff aware of residents at risk of adverse events such as pressure ulcers and falls … help prevent four adverse events: pressure ulcers, pressure ulcers that are not healing appropriately, falls … On-Time reports for preventing falls and avoidable hospitalizations are currently in development. … Pressure Ulcer Healing, Falls, and Avoidable Hospitalization reports and worksheets have been tested … is designed to identify residents at risk for the adverse event of interest (e.g., pressure ulcers, falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18c.html
December 01, 2012 - Pressure Ulcer
3,451
1,762
2,142
2,427
2,827
1,758
3,323
1,746
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18.html
December 01, 2012 - Pressure Ulcer
4,443
3,028
3,450
3,527
4,157
2,822
4,392
2,997
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18g.html
December 01, 2012 - Pressure Ulcer
5,116
3,763
3,806
4,740
5,358
3,126
5,260
3,679
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18f.html
December 01, 2012 - Pressure Ulcer
6,748
4,003
4,586
5,403
6,035
3,967
6,763
3,893
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18e.html
December 01, 2012 - Pressure Ulcer
3,464
2,296
2,799
2,580
3,066
2,178
3,313
2,292
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18d.html
December 01, 2012 - Pressure Ulcer
1,757
1,227
1,653
1,218
1,537
1,233
1,672
1,232
Injurious Falls
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab18b.html
December 01, 2012 - Pressure Ulcer
4,754
3,486
3,908
3,901
4,595
3,208
4,736
3,445
Injurious Falls
-
www.ahrq.gov/sites/default/files/2024-12/thorpe-rask-report.pdf
January 01, 2024 - to Patient Safety Issues-Medical Events (PSI-ME) Self-
Assessments (SA):
a. 2003 Medical Errors (falls … three options:
i. 108 hospitals elected to continue to use the current self-assessment process
for falls … Enables the user to evaluate the organization’s falls prevention program,
develop an improvement plan … Safe Medication Use Improvement Plans and
Reassessment Forms
• Sentinel Events Reporting Tool
• Falls … Edits and/or new questions were recommended for the Sentinel Events
Reporting Tool, Falls Assessment
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/techdocrpt-appb.pdf
January 01, 2019 - , SD,
57108-5717
Avera Health 3900 W AVERA
DR,
Sioux Falls, SD,
57108-5717
Avera Health 3900 … WEST AVERA
DRIVE, Sioux Falls,
SD,
57108-5721
HSI00000069 Avita Health System 269 PORTLAND
WAY … System
1101 26TH STREET
SOUTH, Great Falls,
MT,
59405-5161
HSI00000108 Berger Health System … CHURCH,
VA,
22042-1252
Inova Health System 8110 GATEHOUSE
RD, Falls Church,
VA,
22042-1217 … Memorial Medical Center 621 10TH ST,
NIAGARA FALLS,
NY,
14301-1813
Niagara Falls Memorial
Medical
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
April 21, 2008 - Reduced patient
falls
• To promote a culture of safety by
encouraging reporting of near-miss
falls … • To identify and implement
interventions and strategies to
reduce patient falls and harm. … use of bed alarms, patient fall risk identifiers, and their staff’s
perception of patients’ risk for falling … We have used these reports to identify patterns and trends related to when
falls occur, as well as common … more about human factors alerted us to several significant
documentation requirements for reporting falls
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/npsd-spotlight_behavioral-health.pdf
September 01, 2025 - following medical advice about discharge can have an increased risk of
medical problems, including falls … safety event. 1,927 11.6%
459 16.7%
EVENT TYPE
Other 9,151 54.9% 2,119 77.0%
Falls … Table 5, the percentage of other events with at least one BH issue was
15.3 percent, followed by falls … 5%
9%
1% 1% 2%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
22%
24%
26%
28%
30%
Other Falls … Total
Percent
Percent with
at least one
BH issue**
Other 13.6% 7.1% 1.7% 6.8% 29.2% 15.3%
Falls
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-teamwork-leadership-2025.pdf
January 01, 2025 - :
Collaboration and
Proactive Teamwork
Used To Reduce Falls
2012–2014
$599,990
Purpose: To implement … • The repeat fall rate within a hospital was negatively associated with the
percentage of falls that … • Over a 2-year period, 353 falls were reported; 32% of the falls were
injurious and 75% were unassisted … Identifying a gait belt as an intervention decreases the odds of
patients falling unassisted. … Purpose and Key Findings/Impact
Number of Publications (Products)
Department of
Defense, TRICARE
Falls