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Search results for "United States of America"

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Journal Article > Commentary

The tension between promoting mobility and preventing falls in the hospital.

Growdon ME, Shorr RI, Inouye SK. JAMA Intern Med. 2017;177:759-760.

This commentary discusses unintended consequences of the well-intentioned strategy of keeping older adults in bed while hospitalized to reduce falls, a never event. The authors suggest that immobilizing patients is not the answer to fall prevention and advocate for hospitals to promote patient mobility as a routine part of care.

Journal Article > Study

Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls.

Bursiek AA, Hopkins MR, Breitkopf DM, et al. J Patient Saf. 2017 Mar 7; [Epub ahead of print].

Fall prevention is a critical patient safety activity. This pre–post study of simulation-based team training resulted in higher teamwork scores and lower rates of preventable falls over time. These results lend support to team training as a strategy to improve patient safety.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Book/Report

Preventing Patient Falls: A Systematic Approach From the Joint Commission Center for Transforming Healthcare Project.

Chicago, IL: Health Research & Educational Trust; October 2016.

Falls are a common hazard among both hospitalized and ambulatory patients. This report summarizes the results of a collaborative to identify and address the root causes of falls in hospitals and provides case studies from the participating organizations to illustrate their experiences during the initiative.

Journal Article > Review

A systematic review of the unintended consequences of clinical interventions to reduce adverse outcomes.

Manojlovich M, Lee S, Lauseng D. J Patient Saf. 2016;12:173-179.

Interventions intended to enhance patient safety may have unanticipated consequences. This systematic review found that unintended consequences of patient safety interventions, positive and negative, are common. Researchers recommend that all patient safety interventions should be monitored for these unexpected outcomes.

Book/Report

Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm.

Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.

Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.

Special or Theme Issue

Special Issue on Falls.

Rehabil Nurs. 2016;41:1-59.

Safety challenges in residential care facilities are well documented. Articles in this special issue explore falls in rehabilitation settings, including nurses' role in managing fall risks and strategies to prevent falls.

Journal Article > Commentary

Safety standards: implementing fall prevention interventions and sustaining lower fall rates by promoting the culture of safety on an inpatient rehabilitation unit.

Leone RM, Adams RJ. Rehabil Nurs. 2016;41:26-32.

Inpatient falls are a pervasive sentinel event that require improvements in processes and the environment to achieve sustainable reductions. This commentary discusses how engaging nurse leadership in fall prevention efforts in a rehabilitation unit decreased fall rates and sustained this improvement by promoting a culture of safety.

Legislation/Regulation > Sentinel Event Alerts

Preventing falls and fall-related injuries in health care facilities.

Sentinel Event Alert. September 28, 2015;(55):1-5.

Falls in the hospital are common, particularly among elderly patients, and falls resulting in serious injury or death are considered never events. This sentinel event alert identified 465 such cases reported to The Joint Commission since 2009 and acknowledges that preventing falls is difficult and complex. The Joint Commission recommends several strategies for preventing falls, including identifying patients at risk for falls, establishing a multidisciplinary fall prevention team, using patient-specific approaches to minimize fall risk, and conducting a post-fall multidisciplinary huddle to detect system flaws. These strategies have been successfully applied and shown to reduce falls in high-quality studies. The role of the physical environment as a risk for falls and the use of post-fall huddles are discussed in a recent AHRQ WebM&M commentary.

Tools/Toolkit

Preventing Falls With Injury.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; August 2015.

Patient falls are preventable and can be addressed through quality and safety strategies. This toolkit provides a process to help health care organizations determine factors that contribute to falls in their facilities and design interventions to drive improvement.

Journal Article > Commentary

Reducing falls with a safety spotter program.

Primmer P, Borenstein KK, Downing MT, et al. Nursing. 2015;45:16-19.

Patients at high risk for falls can be targeted for personalized prevention interventions, but such efforts can be costly for hospitals. This commentary describes how a hospital employed "spotters" to watch and interact with patients at risk for falls, with one spotter assigned to monitor up to four patients, and found the results to be affordable and effective.

Journal Article > Commentary

Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.

Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.

Journal Article > Commentary

At risk care plans: a way to reduce readmissions and adverse events.

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.

Audiovisual

To reduce patient falls, hospitals try alarms, more nurses.

Ryan J. All Things Considered. National Public Radio. October 16, 2013.

This radio news segment reports on patient falls, including risk factors and prevention strategies.

Journal Article > Study

Patient safety incidents in hospice care: observations from interdisciplinary case conferences.

Oliver DP, Demiris G, Wittenberg-Lyles E, Gage A, Dewsnap-Dreisinger ML, Luetkemeyer J. J Palliat Med. 2013;16:1561-1567.

The number of patients receiving home hospice services is growing, and this descriptive study found that medication errors and falls appear to be among the prominent patient safety concerns in such patients.

Journal Article > Commentary

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

Quigley PA, Barnett SD, Bulat T, Friedman Y. J Nurs Care Qual. 2014;29:51-59.

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

Journal Article > Commentary

Partnering to prevent falls: using a multimodal multidisciplinary team.

Volz TM, Swaim TJ. J Nurs Adm. 2013;43:336-341.

This commentary describes an initiative that reduced falls at a large health care system and highlights a weekly discussion strategy as a main contributor to the program's success.

Newspaper/Magazine Article

The no-fall zone.

Butcher L. Hosp Health Netw. June 2013.

This magazine article explores patient falls and describes strategies to prevent them, including transparency, teach-back, and hallway monitor screens.

Journal Article > Review

Inpatient fall prevention programs as a patient safety strategy: a systematic 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.

Tools/Toolkit > Government Resource

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.

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.

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