The patient who falls: "It's always a trade-off."

Mary E Tinetti; Chandrika Kumar

Commentary

The patient who falls: "It's always a trade-off."

January 27, 2010

Tinetti ME, Kumar C. JAMA. 2010;303(3):258-66.

View more articles from the same authors.

Through a case study, this article reviews evidence on risk factors for and interventions to reduce falls in community-dwelling older adults. The authors also describe how to integrate such prevention strategies into clinical practice.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Medicare nonpayment, hospital falls, and unintended consequences.

June 17, 2009

Deprescribing: a simple method for reducing polypharmacy.

September 6, 2017

Collaborating to manage vendor interactions and protect quality of care in the OR.

October 26, 2005

The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety.

January 26, 2022

Racial and ethnic disparities in the treatment of chronic pain.

December 29, 2020

Ethical dilemma in missed melanoma: what to tell the patient and other providers.

May 17, 2017

International perspectives on modifications to the surgical safety checklist.

June 21, 2023

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

November 17, 2021

Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational silence.

August 13, 2014

Modification of potentially inappropriate prescribing following fall-related hospitalizations in older adults.

July 10, 2019

Patient safety instruction in US health professions education.

December 21, 2011

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

November 24, 2021

Dealing honestly with an honest mistake.

January 20, 2010

Safety of clinical and non-clinical decision makers in telephone triage: a narrative review.

April 1, 2015

Effect of a pharmacist on adverse drug events and medication errors in outpatients with cardiovascular disease.

May 6, 2009

Using human factors design principles and industrial engineering methods to improve accuracy and speed of drug selection with medication trays.

October 19, 2016

Improving the bar-coded medication administration system at the Department of Veterans Affairs.

August 9, 2006

Evaluation of a redesign initiative in an internal-medicine residency.

April 21, 2010

Laboratory session to improve first-year pharmacy students' knowledge and confidence concerning the prevention of medication errors.

November 11, 2009

Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner.

September 26, 2007

Decision making in trauma settings: simulation to improve diagnostic skills.

March 11, 2015

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

April 6, 2022

Nurses' satisfaction with medication administration point-of-care technology.

September 5, 2007

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations.

March 17, 2021

Triggers, bundles, protocols, and checklists—what every maternal care provider needs to know.

April 13, 2016

Language proficiency and adverse events in US hospitals: a pilot study.

February 21, 2007

Information gaps in newborn care and their potential for harm.

May 6, 2015

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict.

August 28, 2013

Non-technical skills in surgery during the COVID-19 pandemic: an observational study.

March 9, 2022

Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi.

July 15, 2009

Comparative effectiveness of a serious game and an e-module to support patient safety knowledge and awareness.

February 22, 2017

Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement."

July 21, 2020

Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature.

January 31, 2018

Factors associated with misdiagnosis of acute stroke in young adults.

December 7, 2011

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

December 7, 2016

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.

April 14, 2021

What stage are low-income and middle-income countries (LMICs) at with patient safety curriculum implementation and what are the barriers to implementation? A two-stage cross-sectional study.

August 9, 2017

The use of anatomical side markers in general radiology: a systematic review of the current literature.

August 26, 2020

Resident duty hours and resident and patient outcomes: systematic review and meta-analysis.

November 16, 2022

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

January 12, 2022

Root cause analysis of transfusion error: identifying causes to implement changes.

December 22, 2010

Five reasons for optimism on World Patient Safety Day.

October 23, 2019

Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid dispensation in Alberta, Canada.

June 16, 2021

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse.

July 24, 2019

A prospective study to evaluate awareness about medication errors amongst health-care personnel representing North, East, West Regions of India.

March 26, 2014

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

January 18, 2006

Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.

April 18, 2012

Does error and adverse event reporting by physicians and nurses differ?

August 27, 2008

Voluntary electronic reporting of medical errors and adverse events.

January 18, 2006

Automation of the I-PASS tool to improve transitions of care.

October 23, 2019

Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems.

August 1, 2012

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review.

April 7, 2021

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

May 8, 2019

Patients' experiences and perspectives of patient-reported outcome measures in clinical care: a systematic review and qualitative meta-synthesis.

May 11, 2022

Variability in the concentrations of intravenous drug infusions prepared in a critical care unit.

August 27, 2008

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients.

April 21, 2005

Leading successful rapid response teams: a multisite implementation evaluation.

April 29, 2009

The challenge of competency assessment of the late-career practitioner.

February 9, 2022

Association between hospital penalty status under the Hospital Readmission Reduction Program and readmission rates for target and nontarget conditions.

January 18, 2017

Parental misinterpretations of over-the-counter pediatric cough and cold medication labels.

July 1, 2009

Disclosing errors to patients: perspectives of registered nurses.

January 14, 2009

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

December 8, 2010

Sustaining the gains: a 7-year follow-through of a hospital-wide patient safety improvement project on hospital-wide adverse event outcomes and patient safety culture.

June 10, 2020

Controlled trial to improve resident sign-out in a medical intensive care unit.

August 30, 2017

In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.

February 22, 2023

I'm sorry: laws that support apologies in health care.

February 5, 2020

Harveian Oration 2018: improving quality and safety in healthcare.

February 13, 2019

Prescribing errors in hospital practice.

October 3, 2012

Techniques to improve patient safety in hospitals: what nurse administrators need to know.

September 19, 2012

Frailty and potentially inappropriate prescribing in older people with polypharmacy: a bi-directional relationship?

August 31, 2022

The second victim: a contested term?

December 1, 2021

Medication safety: look-alike/sound-alike drugs in home care.

April 27, 2005

Crew resource management: applications in healthcare organizations.

September 27, 2006

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital.

February 13, 2008

Hospital-readmission risk--isolating hospital effects from patient effects.

September 20, 2017

Outcomes of daytime procedures performed by attending surgeons after night work.

September 2, 2015

A culture of civility: positively impacting practice and patient safety.

April 25, 2018

Maximizing smart pump technology to enhance patient safety.

July 29, 2015

Cleaning up the discharge process: a number of components—and personnel—are crucial to success.

October 20, 2010

Safety huddles in the PACU: when a patient self-medicates.

April 6, 2011

Participation in a system-thinking simulation experience changes adverse event reporting.

July 8, 2020

Adverse events: root causes and latent factors.

February 15, 2012

Patient safety and the problem of many hands.

March 30, 2016

The Food and Drug Administration's initiative for safe design and effective use of home medical equipment.

June 18, 2014

After Mid Staffordshire: from acknowledgement, through learning, to improvement.

August 27, 2014

Simulation based adverse event reporting system: development and feasibility.

July 30, 2014

HomeNet: ensuring patient safety with medical device use in the home.

June 3, 2009

Unintended exposure in radiotherapy: identification of prominent causes.

October 21, 2009

Safety-I, Safety-II and resilience engineering.

November 6, 2015

March 7, 2007

Theoretical approaches for investigating patient safety.

June 1, 2005

Using clinical simulation to study how to improve quality and safety in healthcare.

September 29, 2018

Estimating deaths due to medical error: the ongoing controversy and why it matters.

October 26, 2016

Elimination of emergency department medication errors due to estimated weights.

May 24, 2017

Is evidence guiding practice? Reported versus observed adherence to contact precautions: a pilot study.

August 28, 2013

'Bad apples': time to redefine as a type of systems problem?

June 26, 2013

When doing wrong feels so right: normalization of deviance.

March 25, 2015

Examining the relationship among ambulatory surgical settings work environment, nurses' characteristics, and medication errors reporting.

January 27, 2016

Team training for safer birth.

January 6, 2016

Competence and certification of registered nurses and safety of patients in intensive care units.

March 18, 2009

Related Resources

The spectrum of hospitalization-associated harm in the elderly.

July 26, 2023

The challenge of risk prevention in home healthcare-an interview study with nurses in municipal care.

July 12, 2023

Patient falls while under supervision: trends from incident reporting.

July 5, 2023

Approaches to improving patient safety in integrated care: a scoping review.

June 14, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Family conferences to facilitate deprescribing in older outpatients with frailty and with polypharmacy: the COFRAIL cluster randomized trial.

May 10, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Journal Article

Study

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

March 29, 2023

Patient perception of fall risk and fall risk screening scores.

March 15, 2023

Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool.

January 25, 2023

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

January 11, 2023

Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital.

September 14, 2022

WebM&M Cases

Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy

August 31, 2022

From COVID-19 pandemic to patient safety: a new "spring" for telemedicine or a boomerang effect?

July 27, 2022

Opioids and falls risk in older adults: a narrative review.

May 25, 2022

The source of purchased medications and its impact on medication mistakes and hospitalizations.

March 16, 2022

Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.

March 9, 2022

Outcomes-based nurse staffing during times of crisis and beyond.

February 16, 2022

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

February 2, 2022

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

January 12, 2022

Call to action: addressing pediatric fall safety in ambulatory environments.

December 1, 2021

DEEP SCOPE: a framework for safe healthcare design.

October 13, 2021

Interview

In Conversation With... José A, Morfín, MD, FASN

April 28, 2021

Perspectives on Safety

Patient Safety in Home Dialysis

April 28, 2021

In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings.

March 24, 2021

Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home.

February 17, 2021

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

February 10, 2021

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

January 27, 2021

Virtual urgent care quality and safety in the time of Coronavirus.

January 20, 2021

Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology.

August 5, 2020

See More About The Topic

Home Care

Health Care Providers

Geriatrics

Patient Falls

Human Factors Engineering

The patient who falls: "It's always a trade-off."

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The patient who falls: "It's always a trade-off."

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site