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Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis.

Paulik O, Hallen J, Lapkin S, et al. Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis. J Patient Saf. 2022;18(3):e613-e619. doi: 10.1097/pts.0000000000000897

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April 13, 2022
Paulik O, Hallen J, Lapkin S, et al. J Patient Saf. 2022;18(3):e613-e619.

Patient falls are considered a never event and can result in serious injury. This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement recommendations proposed after investigation of the event. The researchers classified 8.5% of recommendations as ‘strong’ (i.e., environmental modifications, equipment/process redesign), 35.7% as ‘medium’ (i.e., changing documentation process and/or skill mix, providing education) and 55.8% as ‘weak’ (i.e., alerts or warnings).

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Paulik O, Hallen J, Lapkin S, et al. Strength of improvement recommendations from injurious fall investigations: a retrospective multi-incident analysis. J Patient Saf. 2022;18(3):e613-e619. doi: 10.1097/pts.0000000000000897