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321. Resources by National Action Plan Foundational Area | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/resources/foundational-area.html
     March 01, 2025 - Healthcare Workers This workbook helps healthcare workers recognize and reduce risks for slips, trips, and falls … The workbook also offers support for implementing a slip, trip, and falls prevention program in a healthcare

322. Creating a Work-Around to Implement Fall Risk Screening For Older Adults Using Appointment Notes Case Study (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/opioids/compendium/opioids-case-study-work-around.pdf
     June 02, 2025 - 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…

323. Table 18F: HCBS Population Ages 18-64 Without I/DD or SMI | Agency for Healthcare Research and Quality
     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

324. Table 18G: HCBS Population Age 65 | Agency for Healthcare Research and Quality
     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

325. Table 18A: National HCBS Population | Agency for Healthcare Research and Quality
     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

326. Table 18B: Dually Eligible HCBS Participants | Agency for Healthcare Research and Quality
     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

327. Table 18D: Intellectual/Developmental Disabilities Subpopulation | Agency for Healthcare Research and Quality
     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

328. Table 18E: Serious Mental Illness Subpopulation | Agency for Healthcare Research and Quality
     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

329. Table 18C: Medicaid-Only HCBS Participants | Agency for Healthcare Research and Quality
     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

330. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
     November 01, 2021 - • Patient safety concerns such as falls, pressure injuries, and adverse medication events were reported … Conditions The CFER-H technical specifications capture 10 types of patient safety concerns (e.g., falls … of reports, patient safety concerns that are typically not associated with the COVID- 19 PHE (e.g., falls

331. Puh-Factraining-Guide (doc file)
     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

332. Final Progress Report: Accountability and Health Safety – A Statewide Approach (pdf file)
     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

333. Transcript-Speaking-Up (doc file)
     www.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

334. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     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

335. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/facility-transfer.html
     September 01, 2017 - Total Counts Asthma Circulatory Problems Hypertension Gastroenteritis Angina Falls

336. Comparative Health System Performance Initiative: Compendium of U.S. Health Systems, 2016, Technical Documentation-Appendix B (pdf file)
     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

337. Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes (pdf file)
     www.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

338. Generic Dashboard Data 2024 (xls file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
     January 01, 2024 - 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, 2023. The tables include distributions of events and…

339. Job Aid: Standardized Quality Measures (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-standardized-quality-measures.pdf
     June 02, 2025 - 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…

340. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=16
     September 01, 2012 - address detecting change in a resident's condition, communicating change in a resident's condition, and falls