Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.

Aleksandra A. Zecevic; Alan W. Salmoni; John H. Lewko; Anthoney A. Vandervoort; Mark Speechley

Study

Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.

July 1, 2009

Zecevic AA, Salmoni AW, Lewko JH, et al. Gerontologist. 2009;49(5):685-96.

View more articles from the same authors.

Root cause analysis methodology was used to identify predisposing causes of falls in geriatric patients.

PubMed citation

Available at

Related Resources From the Same Author(s)

Understanding safety culture in long-term care: a case study.

March 26, 2014

Safety culture in healthcare: a review of concepts, dimensions, measures and progress.

April 13, 2011

Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

July 8, 2015

Preventing diagnostic errors in primary care.

October 12, 2016

Checklists to reduce diagnostic errors.

February 9, 2011

Disruptive behavior affects hospital financial health.

December 22, 2010

Managing disruptive behaviors in the health care setting: focus on obstetrics services.

May 18, 2011

The quality and economic impact of disruptive behaviors on clinical outcomes of patient care.

May 4, 2011

Pain states, the opioid epidemic, and the role of radiologists.

April 4, 2018

Resident hesitation in the operating room: does uncertainty equal incompetence?

November 21, 2018

Incidence and impact of physician and nurse disruptive behaviors in the emergency department.

May 4, 2011

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

Teamwork errors in trauma resuscitation.

September 26, 2012

Safer care at home: use of simulation training to improve standards.

October 19, 2011

Texting while doctoring: a patient safety hazard.

December 18, 2013

A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.

September 7, 2005

The impact of anti-infective drug shortages on hospitals in the United States: trends and causes.

February 8, 2012

A survey of the impact of disruptive behaviors and communication defects on patient safety.

August 13, 2008

Invited article: Managing disruptive physician behavior: impact on staff relationships and patient care.

May 7, 2008

Impact and implications of disruptive behavior in the perioperative arena.

July 12, 2006

Disruptive behavior and clinical outcomes: perceptions of nurses and physicians.

April 21, 2005

Patients use an internet technology to report when things go wrong.

June 20, 2007

The effect of the fit between organizational culture and structure on medication errors in medical group practices.

February 7, 2007

Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.

April 23, 2014

The contribution of labelling to safe medication administration in anaesthetic practice.

June 15, 2011

Beyond FMEA: the structured what-if technique (SWIFT).

September 26, 2012

The Anesthesia Patient Safety Foundation at 25: a pioneering success in safety, 25th anniversary provokes reflection, anticipation.

February 1, 2012

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

June 10, 2009

Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education.

April 4, 2007

"That was a close call": endorsing a broad definition of near misses in health care.

October 2, 2013

Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.

September 1, 2010

The influence of the structure and culture of medical group practices on prescription drug errors.

August 31, 2005

Patient safety attitudes and behaviors of graduating medical students.

September 21, 2011

Differences in safety climate among hospital anesthesia departments and the effect of a realistic simulation-based training program.

February 20, 2008

The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care.

August 24, 2005

Effect of reducing interns' work hours on serious medical errors in intensive care units.

March 27, 2005

Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of transfusion scheme 1996-2005.

June 25, 2008

Assessing the impact of teaching patient safety principles to medical students during surgical clerkships.

July 20, 2011

Same-hospital readmission rates as a measure of pediatric quality of care.

August 12, 2015

Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals.

September 1, 2021

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.

January 15, 2020

Organizational factors associated with high performance in quality and safety in academic medical centers.

February 27, 2008

Pharmacy–nursing intervention to improve accuracy and completeness of medication histories.

April 28, 2010

A descriptive study of nurse-reported missed care in neonatal intensive care units.

May 6, 2015

Association of nurse workload with missed nursing care in the neonatal intensive care unit.

November 21, 2018

Contextual information influences diagnosis accuracy and decision making in simulated emergency medicine emergencies.

June 12, 2013

Implementation of a patient safety program at a tertiary health system: a longitudinal analysis of interventions and serious safety events.

May 9, 2018

Aiming higher to enhance professionalism: beyond accreditation and certification.

May 27, 2015

Close calls in patient safety: should we be paying closer attention?

May 15, 2013

Primary medication non-adherence: analysis of 195,930 electronic prescriptions.

February 17, 2010

Virtual patients designed for training against medical error: exploring the impact of decision-making on learner motivation.

May 15, 2019

Health care workers as second victims of medical errors.

May 11, 2011

Hospital inpatient falls across clinical departments.

September 1, 2021

The interpretability of doctor identification badges in UK hospitals: a survey of nurses and patients.

June 25, 2014

Patient safety and the question of dignitary harms.

March 15, 2023

Underlying reasons associated with hospital readmission following surgery in the United States.

February 18, 2015

Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.

December 7, 2016

Psychology of error in relation to medical practice.

March 6, 2005

A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.

June 20, 2012

Impact of alarm fatigue on the work of nurses in an intensive care environment--a systematic review.

February 3, 2021

The relationship between perceived practice quality and quality improvement activities and physician practice dissatisfaction, professional isolation, and work-life stress.

August 5, 2009

How to perform a root cause analysis for workup and future prevention of medical errors: a review.

October 19, 2016

Enhanced detection of blood bank sample collection errors with a centralized patient database.

February 18, 2009

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

April 28, 2010

Medication errors involving pediatric patients.

June 8, 2005

Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study.

November 14, 2018

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study.

March 11, 2020

FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

October 22, 2014

A controlled trial of a rapid response system in an academic medical center.

June 25, 2008

Translating patient safety legislation into health care practice.

November 29, 2006

Sleep and circadian misalignment for the hospitalist: a review.

August 3, 2016

Walking the plank: an experimental paradigm to investigate safety voice.

July 31, 2019

An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes.

December 13, 2006

Hospital process compliance and surgical outcomes in Medicare beneficiaries.

October 27, 2010

Attitudes to patient safety amongst medical students and tutors: developing a reliable and valid measure.

October 28, 2009

System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model.

January 20, 2016

The next organizational challenge: finding and addressing diagnostic error.

March 5, 2014

Teamwork and team training in the ICU: where do the similarities with aviation end?

December 21, 2011

Does one size fit all? Assessing the need for organizational second victim support programs.

April 7, 2021

The business case for patient safety.

February 14, 2007

Preventable deaths: who, how often, and why?

March 27, 2005

Overdiagnosis: how our compulsion for diagnosis may be harming children.

December 3, 2014

Intralipid medication errors in the neonatal intensive care unit.

February 14, 2007

Adverse drug event reporting in intensive care units: a survey of current practices.

August 2, 2006

A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient beds.

April 8, 2009

Cause and effect analysis of closed claims in obstetrics and gynecology.

May 18, 2005

Using Medical Emergency Teams to detect preventable adverse events.

September 9, 2009

Medication errors resulting from computer entry by nonprescribers.

May 6, 2009

Potential medication dosing errors in outpatient pediatrics.

January 11, 2006

Should medical malpractice prevention be considered separately or as an integral part of comprehensive health care safety improvement?

August 28, 2013

Responding to patient safety incidents: the "seven pillars."

April 7, 2010

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education.

May 17, 2017

Effects of learning climate and registered nurse staffing on medication errors.

January 5, 2011

Nurse staffing and medication errors: cross-sectional or longitudinal relationships?

October 29, 2008

Relationship between occurrence of surgical complications and hospital finances.

April 24, 2013

Association between language use and ICU transfer and serious adverse events in hospitalized pediatric patients who experience rapid response activation.

August 17, 2022

Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study.

October 26, 2016

Case: a second victim support program in pediatrics: successes and challenges to implementation.

March 21, 2018

Drug shortage-associated increase in catheter-related blood stream infection in children.

October 31, 2012

Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.

May 13, 2009

Related Resources

Organisational conditions for safety management practice in homecare and nursing homes, pre-pandemic and in pandemic.

March 27, 2024

Unsafe care in residential settings for older adults. A content analysis of accreditation reports.

December 13, 2023

Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention.

November 29, 2023

Innovative approaches to analysing aged care falls incident data: International Classification for Patient Safety and correspondence analysis.

November 8, 2023

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

September 13, 2023

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

July 12, 2023

Underreporting of quality measures and associated facility characteristics and racial disparities in US nursing home ratings.

June 7, 2023

Patient safety in home health care: a grounded theory study.

May 24, 2023

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

May 10, 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

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

March 1, 2023

Registered nurses' efforts to ensure safety for home-dwelling older patients.

February 22, 2023

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

January 25, 2023

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

January 18, 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

The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide.

August 17, 2022

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

July 20, 2022

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

July 20, 2022

Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.

May 25, 2022

Individualized medication review in older people with multimorbidity: a comparative analysis between patients living at home and in a nursing home.

May 25, 2022

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

Potentially inappropriate medications and their effect on falls during hospital admission.

March 23, 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

Staffing, teamwork and scope of practice: analysis of the association with patient safety in the context of rehabilitation.

December 15, 2021

Perceptions of providing safe care for frail older people at home: a qualitative study based on focus group interviews with home care staff.

November 10, 2021

The effect of providing staff training and enhanced support to care homes on care processes, safety climate and avoidable harms: evaluation of a care home quality improvement programme in England.

August 18, 2021

See More About The Topic

Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.

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

Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.

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

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