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Journal Article > Commentary
Using OrgAhead, a computational modeling program, to improve patient care unit safety and quality outcomes.
Effken JA, Brewer BB, Patil A, Lamb GS, Verran JA, Carley K. Int J Med Inform. 2005;74:605-613.
The authors describe their experience using a computerized model to understand the impact of organizational, patient unit, and patient characteristics on safety and quality. This study was supported with a grant from the Agency for Healthcare Research and Quality (AHRQ).
Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force.
Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Ann Intern Med. 2010;153:815-825.
Falls are a major source of preventable morbidity and mortality for elderly patients in both the ambulatory care and hospital setting. However, efforts to prevent falls have been limited by a lack of high quality evidence supporting specific prevention strategies. This AHRQ-funded systematic review identified several focused interventions, including physical therapy, exercise, and vitamin D supplementation, that appeared to reduce the risk of falls in outpatients. The evidence base in this area has also been strengthened by recent studies showing that patient education and individualized interventions can prevent falls in hospitalized patients.
Tools/Toolkit > Government Resource
Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF.
This toolkit offers information and resources to guide hospitals through process change to implement and sustain fall prevention efforts.
Journal Article > Review
Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.
Considered a never event for hospitalized patients, falls that result in serious injury remain relatively common despite increased attention to the issue. This systematic review identified approaches used to successfully implement fall prevention programs and found high-quality evidence that multicomponent interventions—including patient education, discontinuation of harmful medications, and wristband alerts—can significantly reduce inpatient fall rates. Although concerns have been raised that fall prevention programs could have unintended consequences, this review found that potential harms (such as increased use of sedating medications) had not been systematically evaluated. This review was conducted as part of the AHRQ Making Health Care Safer II report, and on the strength of this evidence, fall prevention strategies are considered one of the top ten patient safety strategies ready for implementation now. An institutional approach to fall prevention is discussed in an AHRQ WebM&M perspective.
Web Resource > Course Material/Curriculum
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training program provides educational webinars and implementation guidance to help hospitals use an AHRQ toolkit to decrease risk of falls. The toolkit draws from a 2-year pilot project that achieved sustained improvements for organizations in the program.
Journal Article > Review
Joseph A, Henriksen K, Malone E. Health Aff (Millwood). 2018;37:1884-1891.
The built environment influences the safety and effectiveness of care delivery. This narrative review examines how care facility design can reduce health care–associated infections, falls, and medication errors. The authors provide suggestions regarding a range of facility design strategies and discuss how accreditation, funding, and policy organizations can support design projects as improvement efforts.