-
digital.ahrq.gov/sites/default/files/docs/implementation/U%20of%20MN%209-17-05.ppt
November 24, 2003 - Background - IOM Report
The risk of dying as a result of medical error far surpasses the risk of dying in … Death on Domestic Flights - 1 in 8,000,000 flights
Background - IOM Report
cont’d
Death in Hospitals … from Medical Errors
1 in 343 Admits to 1 in 764 Admits
Adverse Events in Hospitals
1 in 27 … FMEA at each design stage
Standardization of Location
Involve patients/families in design process … Inpatient Suicides
Transfusion Related Events
Correct Tube-Correct Connector-Correct Hole
Patient Falls
-
digital.ahrq.gov/sites/default/files/docs/publication/r21hs018205-kearns-final-report-2012.pdf
January 01, 2012 - Scope: Falls and fear of falling are about two times more frequent in elderly persons living in
nursing … Scope
Changes in Movement Patterns and Other Risk Factors for Falls
While risk of falling and fear … of falling increase sharply in community-dwelling adults,
particularly for those in their eighties, … Haley Veterans Hospital.50 Transponders worn by residents and
therapists identify the location of each … Haley Veterans Hospital.
-
digital.ahrq.gov/ahrq-funded-projects/care-transitions-app-patients-multiple-chronic-conditions
January 01, 2023 - Care transitions are a vulnerable period for patients, leading to post-discharge adverse events, falls … Outcomes will include engagement of patients and families in their healthcare and the app’s role in the … Complications, such as falls or medication errors, could lead to readmissions. … The app will facilitate pre-discharge conversations with providers, provide personalized falls-reduction … The team will study the app’s effectiveness, noting whether its use decreases falls, adverse medication
-
digital.ahrq.gov/ahrq-funded-projects/evaluation-ahrqs-time-pressure-ulcer-program
January 01, 2023 - Health Care Theme
Clinical Decision Making
Pressure ulcers and injurious falls … Although substantial research has documented that preventing pressure ulcers and falls is possible, these … nursing home staff to develop timely interventions for at-risk residents to reduce the incidence of falls … In addition, several facilities participated in a series of teleconference calls to develop health information … who should be targeted for prevention protocols to reduce hospital and emergency department (ED) visits
-
digital.ahrq.gov/sites/default/files/docs/transforming-guidelines-action-qas-06152023.pdf
June 15, 2023 - Brigham and Women’s Hospital
Shareable, Interoperable Clinical Decision Support for Older Adults: … artifacts are available through CDS Connect:
https://cds.ahrq.gov/cdsconnect/org/brigham-and-womans-hospital … QUESTION: Is there an alert or flag based on a threshold of risk of falling that would
encourage providers … such as social isolation, lack of access
to proper food, contributing factors to seniors experiencing falls … Brigham and Women’s Hospital
Alex C. Spyropoulos, M.D.
-
digital.ahrq.gov/ahrq-funded-projects/past-initiatives/transforming-healthcare-quality-through-health-it/west-virginia-medical
September 29, 2007 - West Virginia Medical Institute: Using IT to Improve Patient Safety in Small, Rural Hospitals … Twenty-eight hospitals currently take part in the program; prior to the AHRQ grant, only six had signed … analyze how rates of events such as patient falls and drug reactions compare with national trends. … In some cases, the data are used to increase hospitals' attention to problems that might be rooted in … One hospital, Bluefield Regional Medical Center, agreed to participate in a pilot project that would
-
digital.ahrq.gov/sites/default/files/docs/page/reduction-in-hospital-acquired-complications-and-infections-quick-reference-guide.pdf
January 01, 2010 - Reduction in Hospital-Acquired Complications and Infections
Advancing Excellence in Health Care www.ahrq.gov … Agency for Healthcare Research and Quality
Health IT
Reduction in Hospital-
Acquired Complications … 80
percent since 1993, totaling $11 billion in hospital
costs.17 In one hospital system, the Braden … Smaller, community
hospitals may lack specialized support services
(such as wound care nursing staff … Prevention
of falls in hospitalized and institutionalized older
people.
-
digital.ahrq.gov/sites/default/files/docs/publication/action-qi-cds-tool-specifications.pdf
May 23, 2013 - X FACILITY The facility or hospital name. … prior the fall
UNIT The unit the fall occurred on
FACILITY The facility (hospital) the fall occurred … for the hospital for which the report was run. … Resulting in Injury: The number of Injuries from a Fall divided by the total number
of falls … Patient Falls (Page 2)
Facility: The facility abbreviation for the hospital for which the report was
-
digital.ahrq.gov/sites/default/files/docs/activity/2011_2900600118_hurd_pdf_3.pdf
January 01, 2011 - June 2009 – January 2012
AHRQ Funding Amount: $1,699,797
Summary: Pressure ulcers and injurious falls … Although substantial research has documented that preventing pressure ulcers
and falls is possible, … to reduce the incidence of injurious falls. … In addition, several facilities
participated in a series of teleconference calls to develop health information … be targeted for prevention protocols to reduce hospital and emergency department
(ED) visits; and 2
-
digital.ahrq.gov/sites/default/files/docs/transforming-guidelines-action-slides-06152023.pdf
June 15, 2023 - Interoperability- data sharing
and interoperability
− EHR adoption office-based
physicians 78%, hospitals … Elders
Background: Fall Prevention in
Community-Dwelling Older Adults
• Community-based falls … • Independence
• Fear of falling
• Loss of independence
• Lifestyle changes
• Following plan at … Exercise reduces falls by 24%. … Control
Group
(N= 5450)
Odds Ratio
(95% CI) P-Value
No of patients/total no
(%)
Appropriate in-hospital
-
digital.ahrq.gov/sites/default/files/docs/activity/health_information_technology_value_in_rural_hospitals_2009_update_pdf_2.pdf
January 01, 2009 - CAH Data Workgroup
identified as having the highest priority for Iowa CAHs were: medication errors, falls … The team also found that the raw in-
hospital mortality rate for acute myocardial infarction (AMI) in … to urban hospitals, in part because many AMI
patients in rural hospitals are transferred to urban hospitals … An instrumental variable approach to
control for this trend caused the difference in in-hospital mortality … Critical access hospital informatics: how two rural Iowa hospitals
overcame challenges to achieve IT
-
digital.ahrq.gov/sites/default/files/docs/citation/u18hs027557-dykes-final-report-2022.pdf
January 01, 2022 - adults reporting falling in the previous year (2). … At Brigham & Women’s Hospital (BWH), a user
experience expert conducted each of these interview types … In Step 1, the CDS identified one urban and five rural patients at risk of falling due to
prescribed … In Step 1, the CDS identified seven urban and four rural patients at risk of falling
due to their osteoporotic … Gender differences in seeking
care for falls in the aged Medicare population.
-
digital.ahrq.gov/ahrq-funded-projects/portals-inpatient-care-evaluating-usability-use-and-patient-experience/citation/exploration
January 01, 2023 - An exploration of the association between inpatient access to tablets and patient satisfaction with hospital … An exploration of the association between inpatient access to tablets and patient satisfaction with hospital … pubmed/31908632
Principal Investigator
McAlearney, Ann Scheck
Project Name
Portals in
-
digital.ahrq.gov/sites/default/files/docs/page/Root_0.ppt
June 01, 2005 - Indianapolis is primarily a hospital network and research based. … – Hospital
Pharmacies
Pharm Hub
Integrated health care system
Clearinghouse
Hospitals
Hospital
Wait … (title comes up)
Click
An example of what an existing RHIO does (Indianapolis - hospital to hospital … – PBM
Hospitals
PBM
Payers
RxHub
PBM
Hospitals
Integrated health care system
Wait (title comes … Click – Physician to hospital examples
Click – Hospital to physician examples
Click – Health care providers
-
digital.ahrq.gov/sites/default/files/docs/page/Root.ppt
June 01, 2005 - Indianapolis is primarily a hospital network and research based. … – Hospital
Pharmacies
Pharm Hub
Integrated health care system
Clearinghouse
Hospitals
Hospital
Wait … (title comes up)
Click
An example of what an existing RHIO does (Indianapolis - hospital to hospital … – PBM
Hospitals
PBM
Payers
RxHub
PBM
Hospitals
Integrated health care system
Wait (title comes … Click – Physician to hospital examples
Click – Hospital to physician examples
Click – Health care providers
-
digital.ahrq.gov/ahrq-funded-projects/health-information-technology-value-rural-hospitals/annual-summary/2008
January 01, 2008 - CAH Data Workgroup identified as having the highest priority for Iowa CAHs were: medication errors, falls … The team also found that the raw in-hospital mortality rate for acute myocardial infarction (AMI) in … to urban hospitals, in part because many AMI patients in rural hospitals are transferred to urban hospitals … An instrumental variable approach to control for this trend caused the difference in in-hospital mortality … Critical access hospital informatics: how two rural Iowa hospitals overcame challenges to achieve IT
-
digital.ahrq.gov/ahrq-funded-projects/sleep-promotion-toolkit-hospitalized-patients
January 01, 2023 - the acute care hospital setting. … care hospital setting. … Individualized sleep promotion in acute care hospitals: managing specific factors that affect patient … Individualized sleep promotion in acute care hospitals: managing specific factors that affect patient … Individualized sleep promotion in acute care hospitals: Identifying factors that affect patient sleep
-
digital.ahrq.gov/ahrq-funded-projects/using-evidence-based-nursing-practices-and-electronic-health-record-decision
January 01, 2023 - Nursing Practices and Electronic Health Record Decision Support to Reduce Fall-related Patient Injuries in … - 01/31/2011
Technology
Clinical Decision Support System
Care Setting
Hospital … the development of care plans and involvement in quality improvement activities in the area of fall … prevention in acute care. … The team examined the "As-Is" state in order to inform the development of the CDS tools.
-
digital.ahrq.gov/organization/brigham-and-womens-hospital
January 01, 2023 - Brigham and Women's Hospital
Assessing the Effects of EHR Optimization … Interventions in Primary Care
Description
This research evaluates the adoption and impact … imaging using standards to allow them to be shareable, interoperable, and scalable; and implement them in … Investigator(s)
Lacson, Ronilda
Advancing Health Information Exchange During Inter-Hospital … research will refine a current health information exchange platform to improve data exchange for inter-hospital
-
digital.ahrq.gov/ahrq-funded-projects/evaluation-stage-3-meaningful-use-objectives-analysis-ok-and-dc
January 01, 2023 - Evaluation of Stage 3 Meaningful Use Objectives: Analysis in Oklahoma and the District of Columbia … Disclaimer
(Persons using assistive technology may not be able to fully access information in … Number
290-10-00033I-2
Funding Mechanism(s)
Accelerating Change and Transformation in … Location
Falls Church
Virginia
Project Dates
09/26/2013 - 09/25/2014
Technology … What will increase the value for hospitals and ambulatory practices implementing the proposed Stage 3