AHRQ Patient Safety Network

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Patient Falls

Origin/Sponsor

•Australia and New Zealand (3)

•North America (77)

Resource Types

•Audiovisual (2)

•Book/Report (10)

•Clinical Guideline (2)

•Journal Article (67)

•Newspaper/Magazine Article (1)

•Special or Theme Issue (4)

•Tools/Toolkit (1)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (6)

•Latent Errors (5)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (30)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (31)

•Communication Improvement (14)

•Human Factors Engineering (15)

•Teamwork (2)

•Specialization of Care (6)

•Logistical Approaches (15)

•Culture of Safety (15)

•Technologic Approaches (8)

•Education and Training (13)

Clinical Areas

•Medicine (53)

•Nursing (26)

•Pharmacy (4)

Target Audience

•Health Care Providers (66)

•Health Care Executives and Administrators (83)

•Non-Health Care Professionals (30)

•Patients (6)

Setting of Care

•Hospitals (63)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (12)

•Outpatient Surgery (3)

1 - 20 of 92

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STUDY

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Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

STUDY

Injury and death associated with incidents reported to the Patient Safety Net.

Reid M, Estacio R, Albert R. Am J Med Qual. 2009;24:520-524.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

STUDY

Inpatient fall prevention: use of in-room Webcams.

Hardin SR, Dienemann J, Rudisill P, Mills KK. J Patient Saf. 2013;9:29-35.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

STUDY

Chronic kidney disease adversely influences patient safety.

Seliger SL, Zhan M, Hsu VD, Walker LD, Fink JC. J Am Soc Nephrol. 2008;19:2414-2419.

STUDY

classic

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

REVIEW

Inpatient fall prevention programs as a patient safety strategy: a systematic review.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.

BOOK/REPORT

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

COMMENTARY

Medicare nonpayment, hospital falls, and unintended consequences.

Inouye SK, Brown CJ, Tinetti ME. N Engl J Med. 2009;360:2390-2393.

SPECIAL OR THEME ISSUE

Elderly Falls.

J Safety Res. 2011;42:415-542.

BOOK/REPORT

Serious Reportable Events in Massachusetts Acute Care Hospitals: January 1, 2008–December 31, 2008.

Executive Office of Health and Human Services, Department of Public Health, Bureau of Health Care Safety and Quality. Boston, MA: Commonwealth of Massachusetts; 2009.

STUDY

Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial.

Shorr RI, Chandler AM, Mion LC, et al. Ann Intern Med. 2012;157:692-699.

STUDY

Is it possible to identify risks for injurious falls in hospitalized patients?

Mion LC, Chandler AM, Waters TM, et al. Jt Comm J Qual Patient Saf. 2012;38:408-413.

STUDY

The cost of serious fall-related injuries at three midwestern hospitals.

Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. Jt Comm J Qual Patient Saf. 2011;37:81-87.

STUDY

The design of the SAFE or SORRY? study: a cluster randomised trial on the development and testing of an evidence based inpatient safety program for the prevention of adverse events.

van Gaal BG, Schoonhoven L, Hulscher ME, et al. BMC Health Serv Res. 2009;9:58.

STUDY

classic

Patients' concerns about medical errors during hospitalization.

Burroughs TE, Waterman AD, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2007;33:5-14.

TOOLKIT

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.

Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

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