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Tools/Toolkit > Toolkit
Ann Arbor, MI: National Center for Patient Safety; 2004.
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in implementing or improving falls prevention efforts. The toolkit provides information on (1) designing a falls prevention and management program; (2) effective interventions for high-risk fall patients; (3) implementing hip protectors for high-risk fall patients; and (4) educating patients, families, and staff on falls and fall-injury prevention. The web version of the toolkit includes a falls notebook for practitioners implementing a program, media tools, and additional resources.
Journal Article > Commentary
Wertenberger S, Wilson J. Nurs Adm Q. 2005;29:303-307.
The authors describe a post-discharge program to assess and adjust the patient's home environment for safety.
Journal Article > Study
Validating domains of patient contextual factors essential to preventing contextual errors: a qualitative study conducted at Chicago area Veterans Health Administration sites.
Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Acad Med. 2017;92:1287-1293.
Contextual errors can occur when health care providers fail to consider a patient's individual context, such as limited literacy, when making a treatment plan. This qualitative study of clinicians identified 12 types of contextual errors that can impede patient self-management and lead to harm. The authors advocate a "contextual differential" to consider these potential errors.