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261. Table 15A: Outcome Indicators by County Demographics | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15.html
     February 01, 2023 - 22,706 18,412 21,951 18,376 Pressure Ulcer 3,341 3,555 3,254 3,604 Injurious Falls … 24,978 20,372 24,196 20,327 Pressure Ulcer 3,678 4,011 3,589 4,072 Injurious Falls … 14,792 13,022 14,282 13,066 Pressure Ulcer 2,167 2,303 2,110 2,330 Injurious Falls … 5,671 5,408 5,482 5,469 Pressure Ulcer 1,184 1,504 1,154 1,549 Injurious Falls … 5,671 5,408 5,482 5,469 Pressure Ulcer 1,184 1,504 1,154 1,549 Injurious Falls

262. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837209/psn-pdf
     May 25, 2022 - Opioids and falls risk in older adults: a narrative review. … Opioids and falls risk in older adults: a narrative review. … https://psnet.ahrq.gov/issue/opioids-and-falls-risk-older-adults-narrative-review Preventing falls is … This article summarizes the relationship between prescription opioids and risk of falls among older … /issue/preventing-falls-and-fall-related-injuries-health-care-facilities https://psnet.ahrq.gov/primer

263. Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure injuries and medication administration errors: an integrative review. | PSNet
     psnet.ahrq.gov/issue/shift-shift-nursing-handover-interventions-associated-improved-inpatient-outcomes-falls
     July 07, 2021 - Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls … Shift‐to‐shift nursing handover interventions associated with improved inpatient outcomes—falls, pressure … to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls … Shift‐to‐shift nursing handover interventions associated with improved inpatient outcomes—falls, pressure

264. Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis. | PSNet
     psnet.ahrq.gov/issue/strength-improvement-recommendations-injurious-fall-investigations-retrospective-multi
     August 17, 2022 - Patient falls are considered a never event and can result in serious injury . … This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement … Study The Stoplight Mobility Alert System for safety and prevention of falls … interventions to reduce duration and variability in delays to identification of serious injury after falls … More About The Topic Hospitals Long-Term Care Quality and Safety Professionals Patient Falls

265. Appendix B10: Primary Care Provider Fax Report and Orders | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb10pcp.html
     February 01, 2023 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix B10: … Care Provider Fax Report and Orders Previous Page Next Page Table of Contents The Falls … Falls Engineer Instructions 1. Fax Cover Sheet 2. … Falls Assessment Report   3.

266. Falls prevention at Mayo Clinic Rochester: a path to quality care. | PSNet
     psnet.ahrq.gov/issue/falls-prevention-mayo-clinic-rochester-path-quality-care
     January 22, 2017 - Commentary Falls prevention at Mayo Clinic Rochester: a path to quality care. … Falls prevention at Mayo Clinic Rochester: a path to quality care. … Falls prevention at Mayo Clinic Rochester: a path to quality care. … September 27, 2016 Special Issue on Falls. … January 6, 2016 Partnering to prevent falls: using a multimodal multidisciplinary team

267. Quality Improvement Clinical Decision Support Tool Specifications (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/action-qi-cds-tool-specifications.pdf
     June 16, 2021 - FALLS The number of falls that occurred for the patient on the unit during the month. … Number of Falls per 1000 Patient Days: The number of falls divided by the number of patient days * … Falls” prior to the fall divided by the total number of falls … for Falls” prior to the fall divided by the total number of falls. … % of Falls with Moderate+ Injury: The number of falls with a moderate or major injury documented

268. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866728/psn-pdf
     September 18, 2024 - https://psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save-lot Falls and falls … This study showed  that after implementing the Fall TIPS program, falls and falls with injury decreased … roi-fall-prevention-intervention-invest-little-save-lot https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes … pilot-testing-fall-tips-tailoring-interventions-patient-safety-patient-centered-fall https://psnet.ahrq.gov/issue/evaluation-patient-centered-fall-prevention-tool-kit-reduce-falls-and-injuries-nonrandomized

269. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/840172/psn-pdf
     November 16, 2022 - The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and … :e947-e952 https://psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-falls-children … Children with physical or cognitive disabilities can be at higher risk for patient safety events, such as falls … One year after SMAS implementation, the research team documented a 60% decrease in the rate of total falls … follow-up from 2015 to 2022, as well as a 33% decrease in falls due to intrinsic factors.

270. Falling Between the Cracks in the Software | PSNet
     psnet.ahrq.gov/web-mm/falling-between-cracks-software
     March 09, 2011 - Falling Between the Cracks in the Software Citation Text: Adler-Milstein J. … Falling Between the Cracks in the Software. PSNet [internet]. … Falling Between the Cracks in the Software. PSNet [internet]. … Falling Between the Cracks in the Software. PSNet [internet].

271. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836865/psn-pdf
     April 06, 2022 - Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls … occupational-therapy-utilization-veterans-dementia-retrospective-review-root- cause-analyses Patient falls … This study explored the causes of falls resulting in harm among patients with dementia receiving or … The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults … https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities

272. Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds. | PSNet
     psnet.ahrq.gov/innovation/demonstrating-value-standardized-cognitive-assessment-tool-through-use-interprofessional
     December 02, 2020 - , traumatic brain injury, or stroke) are particularly vulnerable to patient safety events, such as falls … along a cognition continuum, make proactive changes to the care plan, and decrease the risk of patient falls … and use corresponding interventions to improve care planning, patient safety, and reduce the risk of falls … By December 2020, the fall rate was reduced to 0 falls per 1,000 admissions. … December 15, 2021 Do falls and other safety issues occur more often during handovers

273. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837863/psn-pdf
     August 17, 2022 - The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide. …   https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide … Patient falls are common sentinel events. … The latest revision of this toolkit shares insights on applying the tenets of root cause analysis to falls … https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide https

274. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851051/psn-pdf
     June 28, 2023 - The impact of safety culture, quality of care, missed care and nurse staffing on patient falls: a multisource … The impact of safety culture, quality of care, missed care and nurse staffing on patient falls: a multisource … https://psnet.ahrq.gov/issue/impact-safety-culture-quality-care-missed-care-and-nurse-staffing-patient-falls … , and lower rates of self-reported missed care were associated with a lower incidence of inpatient falls … https://psnet.ahrq.gov/issue/impact-safety-culture-quality-care-missed-care-and-nurse-staffing-patient-falls-multisource

275. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50862/psn-pdf
     February 05, 2020 - Assessment of nursing home reporting of major injury falls for quality measurement on Nursing Home Compare … Assessment of nursing home reporting of major injury falls for quality measurement on nursing home compare … https://psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement … This study compared falls with injury data self-reported by nursing homes against those identified in … Medicare claims data and found that falls with injury were substantially underreported by nursing homes

276. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61113/psn-pdf
     January 01, 2021 - Do falls and other safety issues occur more often during handovers when nurses are away from patients … Do falls and other safety issues occur more often during handovers when nurses are away from patients … https://psnet.ahrq.gov/issue/do-falls-and-other-safety-issues-occur-more-often-during-handovers-when- … This retrospective study examined the incidence of falls during nursing handovers performed in designated … No differences in the incidence of falls or fall severity during handovers performed away from patients

277. Final Progress Report: Improving Patient Safety: Health Systems Reporting, Analysis and Safety Improvement Research Demonstrations (pdf file)
     www.ahrq.gov/sites/default/files/2025-05/fraser-dunagan-report.pdf
     January 01, 2025 - Falls were often unassisted and involved toileting-related activities. … well as care-related factors, such as high patient-to-nurse staffing ratios, increase the risk of falling … and falls involving bedside commodes. … "Patient- and care-related factors associated with falling in the hospital” is currently under peer … Evidenced- Based Strategies for Patient Falls and Wandering.

278. A randomized trial of a multifactorial strategy to prevent serious fall injuries. | PSNet
     psnet.ahrq.gov/issue/randomized-trial-multifactorial-strategy-prevent-serious-fall-injuries
     August 04, 2021 - ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls … December 16, 2020 Evaluation of a patient-centered fall-prevention tool kit to reduce falls … November 15, 2018 Cost of inpatient falls and cost-benefit analysis of implementation … November 16, 2022 Potentially inappropriate medications and their effect on falls during … perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls

279. Fall prevention in acute care hospitals: a randomized trial. | PSNet
     psnet.ahrq.gov/issue/fall-prevention-acute-care-hospitals-randomized-trial
     February 01, 2023 - Patient falls are among the preventable complications of hospital care for which hospitals no longer … Experts in the field have questioned the wisdom of this policy; even though falls are common, little … controlled trial offers an advance in fall prevention, as it demonstrated a significant reduction in falls … Download Citation Related Resources From the Same Author(s) Cost of inpatient falls … November 23, 2016 Patient education to prevent falls among older hospital inpatients:

280. Care Planning Clinical Decision Support Tool Specifications (pdf file)
     digital.ahrq.gov/sites/default/files/docs/publication/action-cp-cds-tool-specifications.pdf
     June 16, 2021 - The prototype tool design was created with only one care plan section for Falls, with a plan to add … o Interventions o Falls (Outcome) • The icons in the problem section were designed to give … and/or Risk for Injury from Falls [plan name]” (Figure 5). … and/or at risk for injury from falls and no plan or orderset is defined” (Figure 6). … At risk for falls At risk for injury due to falls Post-falls (phase) Fields that map to the “Falls