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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
Bright L. Home Healthc Nurse. 2005;23:29-36.
The author presents a program of assessment, education, and follow-up that successfully reduced fall-related injuries.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
Journal Article > Study
Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.
Byrnes MC, Schuerer DJ, Schallom ME, et al. Crit Care Med. 2009; 37:2775-2781.
Adoption of checklists to standardize and mitigate error-prone processes was popularized in patient safety through a compelling 2007 New Yorker article. The concept was further supported by its resounding success in preventing central-line–associated bloodstream infections. Similar efforts have emerged in surgical settings in which adoption of a specific checklist reduced morbidity and mortality. This study implemented a 14-point checklist in the intensive care unit (ICU) setting to actively engage providers in considering best practices during daily rounds and then evaluated whether the checklist affected practice patterns. While the study did not measure clinical patient outcomes, investigators did demonstrate significant improvements in deep vein thrombosis and stress ulcer prophylaxis, oral care for ventilated patients, electrolyte repletion, initiation of physical therapy, and documentation of restraint orders. The study also demonstrated a two-fold increase in transferring patients out of the ICU on telemetry compared with baseline practice. The authors advocate for use of this cost-effective method to promote best practices in ICU settings.
Journal Article > Commentary
Bahle J, Majercik C, Ludwick R, Bukosky H, Frase D. J Nurs Care Qual. 2015;30:200-204.
This commentary describes one hospital's effort to decrease readmissions and adverse events involving inpatients at risk for falls. The authors describe the development and initiation of a targeted care plan that included enhancing care coordination, teamwork, and communication of specialized care needs.