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psnet.ahrq.gov/innovation/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 08, 2021 - Study
The Stoplight Mobility Alert System for safety and prevention of falls
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psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
June 30, 2021 - Study
The Stoplight Mobility Alert System for safety and prevention of falls
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psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
January 13, 2021 - July 31, 2023
Patient Safety Innovations
Preventing Falls
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integrationacademy.ahrq.gov/products/literature-collection/about
September 01, 2024 - Each of the Literature Collection references falls into one or more of the following topics:
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www.ahrq.gov/patient-safety/settings/multiple/index.html
August 01, 2023 - The toolkit addresses approaches to desgin tat target six areas of safety: infections, falls, medication
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmodap2a.html
October 01, 2014 - Falls Prevention
Appendix 1-A. Suggested Slides for Module 1
Appendix 1-B.
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/impaired-visual-acuity-screening-older-adults
June 04, 2020 - to drive and driving outcomes; other measures of morbidity; mortality; cognition; harms, including falls
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psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
August 02, 2015 - Commentary
Emerging Classic
Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem.
Citation Text:
Rosenbaum L. Divided We Fall. N Engl J Med. 2019;380(7):684-688. doi:10…
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psnet.ahrq.gov/issue/workplace-violence-pervasiveness-perioperative-environment-multiprofessional-survey
November 11, 2020 - Study
Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey.
Citation Text:
Lin DM, Lane-Fall MB, Lea JA, et al. Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey. Jt Comm J Qual Patient Saf. 2024;50(11):…
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psnet.ahrq.gov/issue/icu-attending-handoff-practices-results-national-survey-academic-intensivists
February 06, 2019 - Study
ICU attending handoff practices: results from a national survey of academic intensivists.
Citation Text:
Lane-Fall MB, Collard ML, Turnbull AE, et al. ICU Attending Handoff Practices: Results From a National Survey of Academic Intensivists. Crit Care Med. 2016;44(4):690-8. doi:10.1…
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psnet.ahrq.gov/issue/developing-standard-handoff-process-operating-room-icu-transitions-multidisciplinary
February 06, 2019 - Study
Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study.
Citation Text:
Lane-Fall MB, Pascual JL, Massa S, et al. Developing a Standard Handoff Process f…
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psnet.ahrq.gov/issue/what-every-graduating-resident-needs-know-about-quality-improvement-and-patient-safety
March 29, 2023 - Study
What every graduating resident needs to know about quality improvement and patient safety: a content analysis of 26 sets of ACGME milestones.
Citation Text:
Lane-Fall MB, Davis JJ, Clapp JT, et al. What Every Graduating Resident Needs to Know About Quality Improvement and Patient S…
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psnet.ahrq.gov/issue/impact-state-nurse-practitioner-regulations-potentially-inappropriate-medication-prescribing
March 24, 2021 - Study
Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.
Citation Text:
Tzeng H-M, Raji MA, Chou L-N, et al. Impact of state nurse practitioner regulations o…
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psnet.ahrq.gov/innovation/catching-those-who-fall-through-cracks-integrating-follow-process-emergency-department
September 09, 2020 - EMERGING INNOVATIONS
Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.
Citation Text:
Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with …
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effectivehealthcare.ahrq.gov/sites/default/files/cer-229-opioid-treatments-chronic-pain-evidence-summary.pdf
April 01, 2020 - overdose (intentional and unintentional); and
(3) other harms, including gastrointestinal-
related harms, falls … risk of
fracture and three observational studies found an association between opioid use
and risk of falls … cohort study found modest associations between higher dose of long-term
opioid and increased risk of falls … Association of
opioids with falls, fractures, and physical performance
among older men with persistent … Analgesic use
and risk of recurrent falls in participants with or at risk
of knee osteoarthritis: data
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www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/uspstf-annual-report-to-congress-2019.pdf
January 01, 2019 - B
Falls Prevention in Community-Dwelling Older Adults: Interventions in Adults Age 65
Years and Older … at Increased Risk for Falls
The USPSTF recommends exercise interventions to prevent falls in community-dwelling … adults 65 years and older who are at increased risk for falls. … The USPSTF recommends that clinicians selectively offer multifactorial interventions to
prevent falls … to community-dwelling adults age 65 years and older who are at increased
risk for falls.
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - this class of drugs is frequently associated with errors that can result in adverse events including falls … May 26, 2021
WebM&M Cases
Falling Between the Cracks … 28, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - gains
made in the past 10 years—improvements in healthcare-acquired infections, decreases in patient falls … Falls and pressure ulcers also went up – in skilled
nursing facilities, we saw rates of falls causing … including healthcare-
acquired infections, complications, medication safety, safety of the EMR, patient falls
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
September 01, 2017 - record, or EMR, data to make staff aware of residents at risk of adverse events such as pressure ulcers, falls … help prevent four adverse events: pressure ulcers, pressure ulcers that are not healing appropriately, falls … 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
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www.ahrq.gov/news/events/nac/2017-11-nac/nacmtg1117-minutes.html
February 01, 2018 - Topics addressed in new draft recommendations included screening for cervical cancer, prevention of falls … AHRQ released training materials for preventing falls in hospitals. … These five training modules align with chapters in the AHRQ "Preventing Falls in Hospitals" toolkit. … Preliminary data on the use of the training materials showed significant decreases in falls with injury