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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3o.docx
January 01, 2008 - key to maintaining the patient’s safety and for organizational learning about how to prevent future falls … Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls … The tool may be used for the purpose of root cause analysis to prevent future falls in this patient and … Prior to fall, were fall prevention measures in place? … Yes
No
Falls precautions
Fall alert identifier (door sticker)
Bed alarm: if yes, check
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pcmh.ahrq.gov/sites/default/files/publications/files/hacrate2013_0.pdf
October 01, 2015 - Implications for prevention. ADE Prevention Study Group. JAMA 1995;274:29-34. … Reduction of falls-related injuries using a hospital inpatient falls
prevention program. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Evidence-based practice: a falls prevention program that continues to work. … VHA’s national falls collaborative and prevention programs.
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pcmh.ahrq.gov/funding/grantee-profiles/index.html
April 01, 2024 - Medical Director of Epidemiology and Infection Prevention
Professor, Infectious Diseases, School of … More >>
Reducing Patient Falls with Evidence-based Tools
Patricia Dykes, Ph.D., R.N. … Harvard Medical School, Boston, MA “Patient falls can result in traumatic and costly outcomes. … With AHRQ funding, I’ve been able to provide hospitals and primary care practices with falls prevention
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pcmh.ahrq.gov/hai/pfp/hacrate2011-12.html
January 01, 2018 - Centers for Disease Control and Prevention. … Blood Stream Infections Associated With Central Venous Catheters
17,000
0.52
17,000
0.51
Falls … MPSMS
In-Hospital Patient Falls
260,000
7.80
230,000
7.16
Obstetric Adverse Events
PSI
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pcmh.ahrq.gov/patient-safety/settings/hospital/resource/index.html
August 01, 2022 - Patient Safety Research Summaries
Patient Safety Resources by Setting
Hospital
Fall Prevention … Improving Patient Safety Systems for Patients with Limited English Proficiency
NICU Toolkit
Preventing Falls
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pcmh.ahrq.gov/npsd/data/dashboard/index.html
October 01, 2023 - Falls Dashboard
Details the extent of harm due to falls, the presence of fall assistance, presence … New for 2023: Falls Dashboard and Medications or Other Substance Event Supplemental Dashboard
The new … Falls dashboard combines the 2022 supplement’s enhanced analysis of NPSD falls data with data from … and/or mitigate harm from falls, as well as the ability to filter by fall assistance and use of medication … known to increase risk of falls.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/updatedhacrateinfo.pdf
June 01, 2014 - Centers for Disease Control and Prevention. … 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
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pcmh.ahrq.gov/cpi/about/otherwebsites/qualityindicators.ahrq.gov/qualityindicators.html
July 01, 2018 - diagnostic centers) or populations (e.g., mental health or substance abuse, emergency preparedness, patient falls … Products
The current AHRQ QI modules represent various aspects of quality: Prevention Quality Indicators
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pcmh.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/index.html
March 01, 2021 - Implementing Evidence-based Heart Health Care in Asheville
"Cardiovascular disease prevention has the … Steven Brantley (Klamath Falls, OR)
Using Data To Tackle Undiagnosed Hypertension and Improve
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3n.docx
January 01, 2008 - Reference: Adapted from the South Australia Health Fall Prevention Toolkit. … indicated, such as blood sugar levels and x rays.
· Review current care plan and implement additional fall prevention … strategies.
· Provide fall prevention information (Tool 3J). … · Review current care plan and implement additional fall prevention strategies. … · Provide fall prevention information (Tool 3J).
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
November 20, 2014 - Process
Change process strategies can be applied to other quality improvement (QI) efforts:
Hospital falls … (Tool 2C)
Present the assessment of current pressure injury prevention policies and procedures. … recommendations into the action plan.
4
Expected Outcomes
Begin to write a draft Pressure Injury Prevention … Links to quality improvement expertise
Members who influence the areas involved in pressure injury prevention … Pilot Unit Manager
8
Multidisciplinary Team (2A)
Tool 2A
9
QI Process
Link the Pressure Injury Prevention
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pcmh.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - resources to help hospitals and other providers prevent HACs, such as infections, pressure ulcers, and falls … The Centers for Disease Control and Prevention (CDC) data for surgical site infections (SSIs) are also … MPSMS (2015)
Blood Stream Infections Associated With Central Venous Catheters
1,700
0.05
Falls … MPSMS (2015)
In-Hospital Patient Falls
220,000
6.7
Obstetric Adverse Events
PSI (2014) … [7] The AHRQ-developed pressure ulcer toolkit and falls toolkit are online.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
December 01, 2016 - Events
Catheter-Associated Urinary Tract
Infections
Central Line-Associated Bloodstream
Infections
Falls … Events
Catheter-Associated Urinary Tract
Infections
Central Line-Associated Bloodstream
Infections
Falls … Events Catheter-Associated Urinary Tract Infections
Central Line-Associated Bloodstream Infections Falls … Prevention of approximately 87,000 deaths in the 2011 to 2014 period as a result of the decline in
HACs … MPSMS
(2014)
In-Hospital Patient
Falls
260,000 7.9
Obstetric
Adverse
Events
PSI (2014) OB
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pcmh.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html
October 01, 2017 - The Power of Nutrition for Pressure Ulcer Prevention —AHRQ Pressure Injury Prevention Program Implementation … Putting the Nutrition Guidelines into Practice for Pressure Injury Prevention —AHRQ Pressure Injury Prevention … Staff Roles and Training for Your Pressure Ulcer Prevention Program —AHRQ Pressure Injury Prevention … Wound Classification —AHRQ Pressure Injury Prevention Program Training Webinar. … Measuring Pressure Ulcer Rates and Prevention Practices —AHRQ Pressure Injury Prevention Program Training
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pcmh.ahrq.gov/news/newsletters/e-newsletter/index.html
April 30, 2024 - Disabilities
November 14, 2023
Clinical Decision Support Found To Improve Use of Blood Clot Prevention … Surveillance
October 24, 2023
New Data Resource Provides Insights on Factors Related to Falls … Improve Healthcare Quality
May 16, 2023
AHRQ Views: For Women’s Health Week, Let’s Make Prevention
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pcmh.ahrq.gov/news/newsletters/e-newsletter/886.html
October 01, 2023 - Now
Events
New Data Resource Provides Insights on Factors Related to Falls … Today's Headlines:
New Data Resource Provides Insights on Factors Related to Falls . … Falls are one of the most frequently reported patient safety events in the NPSD, second only to medication … patient safety strategies based on increased understanding of factors most commonly associated with falls … Remote patient monitoring improves patient falls and reduces harm .
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pcmh.ahrq.gov/hai/pfp/2014-final.html
January 01, 2018 - Prevention of approximately 87,000 deaths in the 2011 to 2014 period as a result of the decline in HACs … CLABSIs
MPSMS (2014)
Blood Stream Infections Associated With Central Venous Catheters
5,000
0.2
Falls … MPSMS (2014)
In-Hospital Patient Falls
260,000
7.9
Obstetric Adverse Events
PSI (2014) … 50%
50%
25%
10,000
$17,000
.185
$170,000,000
1,850
Falls … 1,040,500
NA
NA
$9,141,150,000
35,647
* Additional costs per HAC for Falls
-
pcmh.ahrq.gov/data/infographics/hac-rates_2019.html
July 01, 2020 - National efforts to reduce hospital-acquired conditions such as adverse drug events and injuries from falls … Falls: 5% decrease. Obstetric events: 3% decrease. Pressure ulcers: 6% increase.
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/spread/spreadnotes.docx
August 28, 2012 - For example, if a hospital is engaged in an organization-wide improvement initiative to decrease falls … Having the Newborn Critical Care Center complete a falls risk assessment for each patient for each shift … For example, for a falls prevention program, quantitative measures to evaluate can include the falls
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pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3f.docx
January 29, 2013 - Measurement
Background: This tool can be used to identify orthostatic hypotension, a risk factor for falls … When a patient is on a medication that may cause orthostasis and has other risk factors for falls. … Tool 3G, ‘STRATIFY Scale for Identifying Fall Risk Factors”) to determine a patient’s risk factors for falls … vomiting, diarrhea, bleeding), have had syncope or near syncope (dizziness, fainting), or are at risk for falls … A significant change in vital signs with a change in position also signals increased risk for falls.