AHRQ Patient Safety Network

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Patient Falls

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (2)

Resource Types

•Clinical Guideline (2)

•Journal Article (65)

•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 (28)

•Legal and Policy Approaches (4)

•Error Reporting and Analysis (29)

•Communication Improvement (14)

•Human Factors Engineering (15)

•Teamwork (3)

•Specialization of Care (5)

•Logistical Approaches (14)

•Culture of Safety (13)

•Technologic Approaches (8)

•Education and Training (13)

Clinical Areas

•Medicine (53)

•Nursing (25)

•Pharmacy (4)

Target Audience

•Health Care Providers (64)

•Health Care Executives and Administrators (78)

•Non-Health Care Professionals (28)

•Patients (5)

Setting of Care

•Hospitals (62)

•Psychiatric Facilities (1)

•Residential Facilities (10)

•Ambulatory Care (12)

•Outpatient Surgery (2)

1 - 20 of 89

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BOOK/REPORT

National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.

National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.

STUDY

Using root cause analysis to reduce falls with injury in community settings.

Lee A, Mills PD, Neily J. Jt Comm J Qual Patient Saf. 2012;38:366-374.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

Inpatient fall prevention: use of in-room Webcams.

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

REVIEW

Patient safety in dermatology: a review of the literature.

Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.

SPECIAL OR THEME ISSUE

Patient Safety Papers.

Baker GE, ed. Healthc Q. 2006;9:1-140.

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.

COMMENTARY

The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.

Pryor DB, Tolchin SF, Hendrich A, Thomas CS, Tersigni AR. Jt Comm J Qual Patient Saf. 2006;32:299-308.

BOOK/REPORT

To Err Is Human—But Don't Expect to Get Paid For It.

ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.

CLINICAL GUIDELINE

Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force.

Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Ann Intern Med. 2010;153:815-825.

STUDY

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

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.

STUDY

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.

SPECIAL OR THEME ISSUE

Elderly Falls.

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

COMMENTARY

Medicare nonpayment, hospital falls, and unintended consequences.

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

BOOK/REPORT

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

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

STUDY

Using root cause analysis to reduce falls with injury in the psychiatric unit.

Lee A, Mills PD, Watts BV. Gen Hosp Psychiatry. 2012;34:304-311.

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.

SPECIAL OR THEME ISSUE

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

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