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301. | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/publications/search.html?page=16
     September 01, 2012 - Clinicians & Providers Data & Measures Education & Training Health Information Technology Health Literacy Hospitals … Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals … This guide presents instructions for hospitals to use to plan and implement patient flow improvement … the development of the Guide to Patient and Family Engagement: Enhancing the Quality and Safety of Hospital … resident's condition, and falls prevention and management.

302. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and ED Visits - Transfer Note and Intake Note (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.pdf
     June 29, 2017 - in reporting: • Transfer date and time • Transfer to location (hospital or ED) • Reason for transfer … a standardized way about the hospital or ED visit upon return to the nursing home, to use it in reporting … admission) • Hospital length of stay or hospital admission date • Treatment received in the ED, if … • Surgical procedures received in the hospital, if applicable Sample Intake Note Resident Name … Admit (Enter one of the following)  Hospital Admission Date OR  Hospital LOS If admitted from

303. Project Summaries for ACTION III Projects Awarded in 2016 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/research/findings/factsheets/translating/action3/actioniii-2016-summaries-revised.pdf
     January 01, 2016 - percentage of falls that resulted in injury and the percentage of each specific type of injury. … Project Settings Project work will be conducted at the Lewin Group offices in Falls Church, Virginia … percentage of falls that resulted in injury and the percentage of each specific type of injury. … The HACs of interest include falls, hospital-acquired pressure ulcers (HAPUs), and several hospital-acquired … • Test the usability of the tool in three to five hospitals.

304. Appendix B1: The FMP Self-Assessment Tool (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb1txt.html
     December 01, 2017 - Monthly falls analysis by # of falls, fallers, patients ≥2 falls, and falls with serious injury?   … History of falls documented in the medical record?                     3. … restraint use side rail use results of fall (BP, BS, mental status, VS, tests ordered, ER or hospital … Improvement in some of the areas requires changes in the facility's management strategies and improvement … in other areas requires changes in care practices.

305. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=152
     January 01, 2024 - Readmissions data for 2,465 hospitals was analyzed using Medicare’s FY 2016 Hospital Compare. … Keywords: Medicare, Hospital Readmissions, Hospitals, Healthcare Costs Kirby JS , Thorlacius … Overall hospital scores improved from 58.1% in 2017 to 66.2% in 2018. … , Health Insurance, Medicaid, Hospitals White EM , Kosar CM , Rahman M Trends in hospitals … Surface perturbation training to prevent falls in older adults: a highly pragmatic, randomized controlled

306. Appendix B2: Tracking Record for Improving Patient Safety TRIPS (Text Description) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb2txt.html
     December 01, 2017 - The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities Appendix B2: … that apply) __ To primary care provider for evaluation __ To emergency room __ Admit to hospital … Was a restraint in use at the time of the incident? … the Falls Management Program at the time of the fall? … __ Yes        If yes, send fax alert to MD. __ No          If no, consider enrollment in the Falls

307. AHRQ Patient Safety Tools and Resources (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/patient-safety-tools-flyer-June2022.pdf
     May 01, 2023 - The toolkit has reduced falls by 25 percent in acute care hospitals and is used in more than 100 hospitals … Web: ahrq.gov/npsd/data/chartbook/index.html Preventing Falls in Hospitals: A Toolkit for Improving … of hospital staff on how to implement AHRQ’s Preventing Falls in Hospitals Toolkit. … the training of hospital staff on how to implement AHRQ’s Preventing Pressure Ulcers in Hospitals … and communicate changes in a resident’s condition and prevent and manage falls.

308. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining-slides.html
     October 01, 2017 - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Facilitator Training Overview … Training Overview of On-Time Slide 2: On-Time Falls Prevention Facilitator Training 2-day … Prevention Preventable Hospital and ED Visits Slide 7: Common Elements of On-Time EMR … Slide 14: Examples of On-Time Reports Examples from Falls Prevention Reports: Falls High-Risk … Quarterly Summary of Falls Risk Factors (by Unit or Facility).

309. AHRQ’s Safety Program for Nursing Homes: On-Time Preventable Hospital and Emergency Department Visits | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/ereports.html
     September 01, 2017 - with preventable hospital and ED visits are grouped in six categories: ED visits within last 90 … pulmonary disease Asthma Circulatory problems Hypertension Gastroenteritis Angina pectoris Falls … In addition, these data can be used in discussions with hospital stakeholders or managed care organizations … obstructive pulmonary disease, asthma, circulatory problems, hypertension, gastroenteritis, angina, falls … Hospital Readmissions (all cause in last 180 days): number of residents readmitted with previous hospital

310. Improving Clinical Performance and Safety Culture Through TeamSTEPPS Implementation
     www.ahrq.gov/sites/default/files/wysiwyg/teamstepps/webinars/2016-materials/teamstepps-monthly-webinar-april2016.pptx
     January 01, 2016 - 2009 Hospitals participated on a voluntary basis beginning in 2010 19 hospitals ranging in size from … continued annually with over 100 hospitals currently engaged in the project TEAMSTEPPS 05.2 Mod 1 … 103 hospitals in 16 states Using TeamSTEPPS for greater than one year 30 additional hospitals in 11 … 133 hospitals in the HCA family using TeamSTEPPS tools by end of 2016 Partnering with the HCA Clinical … team with focus on high functioning teams Requiring more prescriptive measures of success Sepsis, Falls

311. Prologue: Laying the Foundation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Prologue_Henriksen_Vol1.pdf
     July 10, 2008 - systems and surveillance efforts that focus on the intensive care unit, rural and critical access hospitals … , ambulatory pediatric care, primary care, and a teaching hospital obstetrics/gynecology service. … care, the use of ICD-9-CM codes in hospital claims data, adaptation of AHRQ Patient Safety Indicators … risk-binning" methodology applied across institutions, a case-control study to determine risk factors for falls … Veterans Affairs to reduce emergency airway management difficulties, a statewide effort to encourage falls

312. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=301
     January 01, 2024 - Using event reporting systems is the trend for reducing patient safety events such as falls, although … Keywords: Falls, Health Information Technology (HIT), Patient Safety, Web-Based, Adverse Events … The researchers described the development of a knowledge base for patient falls, the most frequent PSE … In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients … Keywords: Adverse Events, Falls, Patient Safety, Prevention Galbraith AA , Meyers DJ , Ross-Degnan

313. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=314
     January 01, 2024 - addition to diagnosis codes to identify falls in the emergency department. … the true burden of falls. … Using chief complaint in addition to diagnosis codes to identify falls in the emergency department. … discharge planning decision tool in community hospitals. … Validating performance of a hospital discharge planning decision tool in community hospitals.

314. Updated Information on the Annual Hospital-Acquired Condition Rate: 2011 and 2012 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
     June 01, 2014 - methods used to compute this data are identical to those used to compute the 2010 baseline, as described in … The data for 2011 and 2012 are shown in Table 1 below. … 32,750,000 Discharges— Based on 2010 Baseline) 2012 PFP Measured HACs per 1,000 Discharge s Falls … MPSMS In-Hospital Patient Falls 260,000 7.80 230,000 7.16 Obstetric Adverse Events PSI OB Trauma … in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) 82,000 2.51 77,000 2.36 Pressure

315. Final Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults (pdf file)
     www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
     January 01, 2025 - back to the ED or the hospital or stay in the hospital longer, which increases exposure to the hazardous … We did not see differences in in repeat falls, VTE, newly prescribed fall risk-increasing drugs, or … Using chief complaint in addition to diagnosis codes to identify falls in the emergency department. … Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. … Transitions of elders between long-term care and hospitals.

316. Network of Patient Safety Databases Chartbook, 2021 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2021.pdf
     January 01, 2021 - • As only data submitted in the Common Formats for Event Reporting-Hospitals (CFER-H) are included … hospitals. … hospitals. … the hospital. … the hospital.

317. Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
     April 01, 2025 - The extent of medical errors in U.S. hospitals was revealed in 2000 when the Institute of Medicine (now … In 2021, 7.1 percent of Medicare patients experienced at least one AE per hospital stay, with 83.6 AEs … Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (PDF, 1.5 MB … adverse drug events and injuries from falls helped prevent 20,700 deaths and saved $7.7 billion between … In addition, MPSMS data from 2010 to 2019 showed decreases from 31 to 39 percent in the number of in-hospital

318. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=494
     January 01, 2024 - can successfully prevent falls. … Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention Braithwaite S , Friedman … Microsimulation was used to assess the financial impact on hospitals of a surge in influenza admissions … Furhter, for a small proportion of hospitals that experienced a high surge in inpatient admissions, increased … The analysis revealed that in the matched cohort, in-hospital and 30-day postdischarge mortality rates

319. AHRQ Safety Expert Chosen To Co-Chair National Effort to Reduce Patient Harm | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/press-releases/national-steering-committee.html
     May 01, 2018 - from falls, there is broad consensus that additional steps must be taken to further protect patients … “There is still so much work to be done in patient safety, in part because we’ve reached the limits of … AHRQ and IHI/NPSF will continue working to produce data, analytics, tools, and resources for hospitals … American Hospital Association. American Nurses Association. … Children’s Hospitals’ Solutions for Patient Safety. DNV GL - Healthcare. ECRI Institute.

320. Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/French.pdf
     April 27, 2004 - Drugs and falls in later life. Lancet 2003 Feb 8;361(9356):448. 7. … Psychotropic drug use, falls and hip fracture in the elderly. … Epidemiology of medication-related falls and fractures in the elderly. … Guideline for the prevention of falls in older persons. … Risk factors for serious injury during falls by older persons in the community.