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psnet.ahrq.gov/issue/call-action-addressing-pediatric-fall-safety-ambulatory-environments
June 30, 2021 - Patient falls represent a significant cause of patient harm. … While most research on falls focus on the in-patient setting, this study reviewed research evidence … and findings from environmental assessments to provide recommendations for reducing risk of falls in … a paediatric hospital. … June 8, 2010
Ounce of prevention: to reduce errors, hospitals prescribe innovative designs
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psnet.ahrq.gov/issue/open-better-care
January 28, 2015 - analysis of the AHRQ Surveys on Patient Safety Culture (SOPS) Workplace Safety Supplemental Items for Hospitals … at a safety net hospital. … falls: enhancing resident safety in long-term care. … February 13, 2013
Aware in Care. … December 5, 2012
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Hospitals
Health
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psnet.ahrq.gov/issue/evidence-guiding-practice-reported-versus-observed-adherence-contact-precautions-pilot-study
June 28, 2017 - Although hospital staff members demonstrated excellent knowledge regarding contact precautions , they … June 28, 2017
Is it possible to identify risks for injurious falls in hospitalized patients … hospitals: a descriptive study. … November 30, 2022
In-hospital sequelae of injurious falls in 24 medical/surgical units … in four hospitals in the United States.
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psnet.ahrq.gov/issue/assessing-effectiveness-engaging-patients-and-their-families-three-step-fall-prevention
February 19, 2020 - July 5, 2017
Families as partners in hospital error and adverse event surveillance. … June 12, 2019
In-hospital sequelae of injurious falls in 24 medical/surgical units in … four hospitals in the United States. … hospital settings. … a specialty cardiac hospital.
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psnet.ahrq.gov/issue/potentially-harmful-medication-dispenses-after-fall-or-hip-fracture-mixed-methods-study
May 05, 2021 - While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. … from 2007-2016, partially associated with the increase in older adults in the population. … , and documentation of falls made it challenging to consider falls when prescribing medications. … February 12, 2020
Determination of unnecessary blood transfusion by comprehensive 15-hospital … of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals
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psnet.ahrq.gov/issue/partnership-patients-pfp-hospital-engagement-network-hen-20-final-report
May 06, 2015 - May 6, 2015
Hand Hygiene Project: Best Practices from Hospitals Participating in the … December 24, 2008
Preventing Patient Falls: A Systematic Approach From the Joint Commission … Related Resources
Patient Safety Innovations
Preventing Falls … Keys to safer hospitals. … December 3, 2008
Hospital-acquired Infections in Pennsylvania.
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psnet.ahrq.gov/periodic-issue/periodic-issue-459
October 30, 2024 - Findings suggest that urban hospitals, smaller hospitals, and hospitals not affiliated with a larger … Findings suggest that urban hospitals, smaller hospitals, and hospitals not affiliated with a larger … Study
Reducing falls in hospitalized children and adolescents with cancer and blood … This article describes a multipronged improvement effort to reduce falls in a pediatric hospital. … This report analyzed a set of patient safety measures in 1,300 hospitals and found that in the first
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psnet.ahrq.gov/node/44872/psn-pdf
February 12, 2016 - Reducing preventable harm in hospitals.
February 12, 2016
Bornstein D. New York Times. … https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
Discussing the importance of designing … collaboratives, including the Partnership for
Patients initiative, as approaches that show promise in … as hospital-acquired infections, patient falls, and
culture change. … partnership-patients
https://psnet.ahrq.gov/issue/partnership-patients
https://psnet.ahrq.gov/issue/preventing-falls-and-fall-related-injuries-health-care-facilities
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psnet.ahrq.gov/issue/safer-hospital-care-strategies-continuous-innovation
October 05, 2022 - Citation Text:
Safer Hospital Care: Strategies for Continuous Innovation, Second Edition. … Resources
Perspective
The Ongoing Journey to Prevent Patient Falls … with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
December 18, 2024 … October 5, 2011
The Patient Safety Initiative at America’s Public Hospitals: The Year … February 9, 2011
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Hospitals
Health
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psnet.ahrq.gov/issue/health-care-facility-design-safety-risk-assessment-toolkit
May 01, 2017 - The toolkit focuses on six areas of safety: infections , falls , medication errors , security, injuries … January 24, 2018
Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs … December 18, 2008
Fall Prevention in Hospitals Training Program. … August 17, 2016
Toolkit for Reducing CAUTI in Hospitals. … December 9, 2015
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care
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psnet.ahrq.gov/issue/harm-free-care
April 15, 2020 - This initiative seeks to reduce four key sources of harm in hospitals: pressure ulcers, falls, catheter-associated … Related Resources
Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital … awaiting long-term care in hospital. … September 14, 2022
Hospital Compare. … January 23, 2019
HealthGrades Sixth Annual Patient Safety in American Hospitals Study
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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 … in a Canadian regional hospital system: a retrospective time series analysis. … delays to identification of serious injury after falls in hospital inpatients. … August 18, 2021
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Hospitals
Long-Term
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psnet.ahrq.gov/issue/evaluation-clinical-practice-guidelines-fall-prevention-and-management-older-adults
March 09, 2022 - September 13, 2023
Opioids and falls risk in older adults: a narrative review. … May 25, 2022
Potentially inappropriate medications and their effect on falls during hospital … July 13, 2022
Opioids and falls risk in older adults: a narrative review. … December 27, 2018
Patient education to prevent falls among older hospital inpatients: … December 21, 2014
Fall prevention in acute care hospitals: a randomized trial.
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psnet.ahrq.gov/issue/safety-standards-implementing-fall-prevention-interventions-and-sustaining-lower-fall-rates
July 12, 2018 - Inpatient falls are a pervasive sentinel event that require improvements in processes and the environment … July 1, 2020
Families as partners in hospital error and adverse event surveillance. … April 6, 2022
Improving hospital safety culture for falls prevention through interdisciplinary … December 23, 2020
A systematic review of falls in hospital for patients with communication … August 14, 2013
An inpatient fall prevention initiative in a tertiary care hospital.
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psnet.ahrq.gov/issue/nosocomial-infection-deficit-reduction-act-and-incentives-hospitals
September 14, 2011 - Nosocomial infection, the Deficit Reduction Act, and incentives for hospitals. … in hospitals: a qualitative study. … January 2, 2013
Minnesota Hospital Association Statewide Project: SAFE from FALLS. … Hospital Care. … October 12, 2011
Medicare nonpayment, hospital falls, and unintended consequences.
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - Age in and of itself is not a good predictor of
falls because there are just as many 75-year-olds playing … Many
patients have a change in status that causes them to be at high risk for falling, and it goes undetected … The hospitals and health care
systems who really get it are using the risk factors in just that way. … In today's complex hospital environment, there are so many alarms going off and
nurses are pulled in … Hospital falls is on that list, which implies that they are identifiable and largely preventable.
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psnet.ahrq.gov/node/837728/psn-pdf
July 27, 2022 - Trends in adverse event rates in hospitalized patients,
2010-2019. … Trends in adverse event rates in hospitalized patients, 2010-2019. … hospitals is a longstanding national priority. … the rates of adverse events (e.g., adverse
drug events, hospital-acquired infections, postoperative … adverse events, hospital-acquired pressure ulcers,
falls) over time among patients hospitalized for
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psnet.ahrq.gov/issue/effect-external-inspections-safety-acute-hospitals-national-health-service-england-controlled
January 12, 2022 - Study
The effect of external inspections on safety in acute hospitals in the National … The effect of external inspections on safety in acute hospitals in the National Health Service in England … did not improve rates of either pressure ulcers or falls. … The effect of external inspections on safety in acute hospitals in the National Health Service in England … awaiting long-term care in hospital.
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psnet.ahrq.gov/issue/patient-safety-culture-and-association-safe-resident-care-nursing-homes
September 19, 2018 - structure ( safety culture ), a process (use of physical restraints), and an outcome (incidence of falls … statistically significant association between higher safety culture scores, lower use of restraints, and fewer falls … the Children's Hospitals' Solutions for Patient Safety Collaborative. … a study of U.S. hospitals. … WebM&M Cases
Failure to Ensure Patient Safety Leads to Patient Falls
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psnet.ahrq.gov/issue/health-information-technology-leadership-panel-final-report
March 30, 2022 - Lewin Group: Falls Church, VA; March 2005. … Lewin Group: Falls Church, VA; March 2005. … a VA hospital: design and outcomes. … January 13, 2021
Adverse Events in Rehabilitation Hospitals: National Incidence Among … June 18, 2013
Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events