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www.uspreventiveservicestaskforce.org/home/getfilebytoken/DTRggkjEPQ5-ALArTjrhKT
July 11, 2017 - There was no evidence of greater
incidence of serious adverse events, injuries, or falls in intervention … Seven physical activity–
focused trials (n = 3565) reported the incidence of injuries, frac-
tures, or falls … trial among women aged 40 to 74 years re-
ported significantly more injuries (19% vs 14%, P = .03) and falls … known cardiovas-
cular risk factors or to prevent or manage other health risks and
conditions (eg, falls
-
effectivehealthcare.ahrq.gov/products/hospital-length-of-stay/protocol
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-removal.pptx
April 01, 2022 - Grant’s risk of falling when getting up to urinate frequently
Disclaimer: All case studies are hypothetical
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hcup-us.ahrq.gov/reports/factsandfigures/2009/highlights.jsp
January 01, 2009 - The rate of stays for circulatory conditions decreased by 13 percent over the 12-year period, falling
-
cdsic.ahrq.gov/sites/default/files/2024-07/Innovation%20Center%20Q2%202024%20Progress%20Report.pdf
January 01, 2024 - The projects vary in terms of expected length of time to complete based on scope, falling into one of
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/medical-office/diagnostic-safety-resources.pdf
May 01, 2023 - It thus potentially
prevents diagnostic errors by preventing patients from “falling through the cracks
-
psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - year-old woman presented to the Emergency Department (ED) for evaluation of “altered mental
status” after falling
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digital.ahrq.gov/sites/default/files/Innovation%20Center%20Q2%202024%20Progress%20Report.pdf
June 26, 2024 - The projects vary in terms of expected length of time to complete based on scope, falling into one of
-
psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - an unsteady gait, suggesting pelvic muscle weakness and requiring use of a “tether” to keep her from falling
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www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
January 01, 2025 - pole so the syringes can be in a more centralized location
• Able to rest on a flat surface without falling
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
December 01, 2017 - Learn From Defects Tool—Perioperative Setting
AHRQ Safety Program for Surgery
What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall.
Problem statement: …
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www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
January 01, 2024 - likely a particular risk is to
contribute to the following events: serious patient safety events (e.g., falls … We also identified
emergent codes representing ideas not falling within our conceptual or coding frameworks
-
hcup-us.ahrq.gov/toolssoftware/ccsr/DXCCSR-User-Guide-v2025-1.pdf
November 01, 2024 - User Guide (v2025.1) for Clinical Classifications Software Refined (CCSR) for ICD-10-CM
USER GUIDE:
CLINICAL CLASSIFICATIONS SOFTWARE REFINED
(CCSR) FOR ICD-10-CM DIAGNOSES, v2025.1
Issued November 2024
Agency for Healthcare Research and Quality
Healthcare Cost and Utilization Project (HCUP)
Phone: (866) 2…
-
www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide7.html
May 01, 2016 - Concern about falling, inadequate staffing, and attitudes about the priority of mobility during hospitalization
-
psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - lethargic, opening her eyes and mumbling incoherently in response to vigorous shaking
but quickly falling
-
psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - The Case
A 65-year-old man was admitted with head and spine trauma after falling from a tree while doing
-
www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide7.html
May 01, 2016 - Concern about falling, inadequate staffing, and attitudes about the priority of mobility during hospitalization
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/study-design-classification_research.pdf
December 01, 2010 - Work-Related Falls Among Union Carpenters in Washington
State Before and After the Vertical Fall Arrest … Outcome(s)
Lipscomb 2003 ITS without
comparison
group
To evaluate changes in rates
and severity of falls … Rates before vs. rates after
enactment of standard
change
Injuries, paid lost time
due to falls … from
elevation, mean direct
payments for falls from
heights
Minassian 2005 Before-after To compare
-
psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
-
psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…