Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

Patricia A. Quigley; Scott D. Barnett; Tatjana Bulat; Yvonne Friedman

Commentary

Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

November 13, 2013

Quigley PA, Barnett SD, Bulat T, et al. J Nurs Care Qual. 2014;29(1):51-9.

View more articles from the same authors.

This commentary relates the experience of five hospitals that implemented different fall prevention programs and reports results of the interventions.

PubMed citation

Available at

Related Resources From the Same Author(s)

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

May 23, 2012

Oncology nurses' beliefs and attitudes towards the double-check of chemotherapy medications: a cross-sectional survey study.

March 21, 2018

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences.

September 7, 2016

Gender, power and leadership: the effect of a superior's gender on respiratory therapists' ability to challenge leadership during a life-threatening emergency.

December 13, 2017

Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation.

August 22, 2007

An evaluation of medication errors—the pediatric surgical service experience.

March 5, 2008

Using prospective risk analysis tools to improve safety in pharmacy settings: a systematic review and critical appraisal.

August 2, 2017

Obstetric practice guidelines: labor's love lost?

June 5, 2019

Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy.

December 19, 2012

Start using a checklist, PRONTO: recommendation for a standard review process for chemotherapy orders.

March 13, 2019

Using failure mode and effects analysis to reduce patient safety risks related to the dispensing process in the community pharmacy setting.

January 24, 2018

Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency.

December 2, 2015

Semi-supervised classification of patient safety event reports.

June 6, 2012

Results of a national neurosurgery resident survey on duty hour regulations.

February 22, 2012

Keeping patients safe in healthcare organizations: a structuration theory of safety culture.

May 11, 2011

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

April 27, 2005

Association of primary care clinic appointment time with opioid prescribing.

September 11, 2019

Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds.

June 29, 2005

Determination of unnecessary blood transfusion by comprehensive 15-hospital record review.

January 25, 2023

Role of registered nurses in error prevention, discovery and correction.

April 16, 2008

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

July 19, 2023

Implementation and evaluation of a prototype consumer reporting system for patient safety events.

June 14, 2017

Rapid response systems: from implementation to evidence base.

November 3, 2010

When clinicians drop out and start over after adverse events.

March 14, 2018

Using inpatient hospital discharge data to monitor patient safety events.

May 8, 2013

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

December 20, 2006

Errors in clinical reasoning: causes and remedial strategies.

June 24, 2009

COVID-19 pandemic and the tension between the need to act and the need to know.

October 14, 2020

Adverse inpatient outcomes during the transition to a new electronic health record system: observational study.

August 10, 2016

Severe staffing and personal protective equipment shortages faced by nursing homes during the COVID-19 pandemic.

September 16, 2020

Care at the point of impact: insights into the second-victim experience.

May 18, 2016

Hospital nurses' work environment characteristics and patient safety outcomes: a literature review.

October 12, 2016

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.

April 21, 2010

Challenging authority and speaking up in the operating room environment: a narrative synthesis.

February 27, 2019

Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel.

October 27, 2021

What are we doing when we double check?

April 1, 2020

Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012.

June 6, 2018

Patient mortality during unannounced accreditation surveys at US hospitals.

April 5, 2017

Opioid-prescribing patterns of emergency physicians and risk of long-term use.

March 1, 2017

Nurses' knowledge and teaching of possible postpartum complications.

August 30, 2017

Patient perception of fall risk and fall risk screening scores.

March 15, 2023

Patient harm from cardiovascular medications.

August 25, 2021

Second victims and mindfulness: a systematic review.

August 21, 2019

Diagnostic challenges in primary care: identifying and avoiding cognitive bias.

June 29, 2022

Cognitive bias and public health policy during the COVID-19 pandemic.

July 22, 2020

Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety.

January 10, 2007

The gaps in specialists' diagnoses.

April 11, 2018

Improving critical incident reporting in primary care through education and involvement.

October 16, 2019

How to develop a second victim support program: a toolkit for health care organizations.

May 2, 2012

Patient safety threats in information management using health information technology in ambulatory cancer care: an exploratory, prospective study.

June 10, 2020

Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians.

March 13, 2019

Coupling policymaking with evaluation—the case of the opioid crisis.

December 20, 2017

Adverse events and emergency department opioid prescriptions in adolescents.

June 30, 2021

Effects of weekend admission and hospital teaching status on in-hospital mortality.

March 6, 2005

September 2, 2009

Prevalence and nature of errors and near errors reported by hospital staff nurses.

March 6, 2005

Improving RCA performance: the Cornerstone Award and the power of positive reinforcement.

August 17, 2011

Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998-2008.

February 18, 2009

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

June 29, 2016

Motivational antecedents of incident reporting: evidence from a survey of nurses and physicians.

November 27, 2013

Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital system.

May 28, 2008

Patient safety climate in primary care: age matters.

March 18, 2009

Improving patient safety: patient-focused, high-reliability team training.

September 10, 2008

Association of sleep and fatigue with decision regret among critical care nurses.

January 29, 2014

Surveillance of medical device-related hazards and adverse events in hospitalized patients.

March 6, 2005

Do patient safety events increase readmissions?

April 8, 2009

Medicare payment for selected adverse events: building the business case for investing in patient safety.

September 27, 2006

Seeing systems in health care organizations.

September 5, 2007

How useful are voluntary medication error reports? The case of warfarin-related medication errors.

January 9, 2008

Characteristics of critical incident reporting systems in primary care: an international survey.

January 19, 2022

The effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism.

December 21, 2016

Promoting patient safety using an early warning scoring system.

August 27, 2008

The impact of duty hours on resident self reports of errors.

March 7, 2007

Implementing a fatigue countermeasures program for nurses: a focus group analysis.

June 2, 2010

Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.

March 27, 2005

Staffing matters—every shift.

December 12, 2012

Nurse burnout syndrome and work environment impact patient safety grade.

August 25, 2021

Should medical errors be disclosed to pediatric patients? Pediatricians' attitudes toward error disclosure.

September 23, 2015

A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.

April 17, 2019

Understanding the roles of three academic communities in a prospective learning health ecosystem for diagnostic excellence.

February 26, 2020

Errors, near misses and adverse events in the emergency department: what can patients tell us?

November 5, 2008

Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses.

August 10, 2016

The Second Victim Experience and Support Tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.

October 22, 2014

High risk prescribing in primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis in Scottish general practice.

July 6, 2011

Evidence of respiratory infection transmission within physician offices could inform outpatient infection control.

September 1, 2021

"Time is of the essence": relationship between hospital staff perceptions of time, safety attitudes and staff wellbeing.

December 8, 2021

CMS changes in reimbursement for HAIs: setting a research agenda.

May 5, 2010

Effect of electronic health records in ambulatory care: retrospective, serial, cross sectional study.

April 15, 2005

Factors associated with intern fatigue.

October 8, 2008

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

May 17, 2017

Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems.

January 13, 2021

Effects of critical care nurses' work hours on vigilance and patients' safety.

January 25, 2006

Performance of International Classification of Diseases, 9th Revision, Clinical Modification codes as an adverse drug event surveillance system.

August 9, 2006

Influence of unit-level staffing on medication errors and falls in military hospitals.

May 18, 2011

Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote workplace safety.

May 17, 2023

Reported clinical incidents of children with intellectual disability: a qualitative analysis.

June 15, 2022

Detection of patient risk by nurses: a theoretical framework.

February 17, 2010

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

March 25, 2020

Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety.

October 17, 2007

Minimizing inappropriate medications in older populations: a ten-step conceptual framework.

April 4, 2012

Related Resources

Should dignity preservation be a precondition for safety and a design priority for healing in inpatient psychiatry spaces?

April 10, 2024

Implementing and evaluating patient-focused safety technology on adult acute mental health wards.

March 13, 2024

Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients.

February 28, 2024

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

August 16, 2023

Why stigma matters in addressing alcohol harm.

August 9, 2023

Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department.

July 26, 2023

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

May 24, 2023

Care Delivery within Community Mental Health Teams.

April 5, 2023

WebM&M Cases

Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.

March 29, 2023

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

March 22, 2023

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

February 15, 2023

Influencing a culture of quality and safety through huddles.

November 9, 2022

Patients who die by suicide: a study of treatment patterns and patient safety incidents in Norway.

November 9, 2022

Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative.

October 5, 2022

Addressing Burnout in the Behavioral Health Workforce through Organizational Strategies.

September 14, 2022

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.

August 17, 2022

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?

May 4, 2022

Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement.

April 20, 2022

To what extent are patients involved in researching safety in acute mental healthcare?

April 6, 2022

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

November 3, 2021

Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care.

October 27, 2021

Patient safety and mental health-a growing quality gap in Canada.

October 6, 2021

Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.

September 1, 2021

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study.

August 11, 2021

Suicide and suicide attempts on hospital grounds and clinic areas.

August 11, 2021

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiatives.

July 21, 2021

The psychological experiences of nurses after inpatient suicide: a meta-synthesis of qualitative research studies.

June 23, 2021

See More About The Topic

Psychiatric Facilities

Health Care Executives and Administrators

Mental Health Care (Psychiatry and Clinical Psychology)

Patient Falls

Epidemiology of Errors and Adverse Events

Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

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