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The information contained in these resources does not necessarily reflect the views of the Partnership for Patients, the Centers for Medicare and Medicaid Services, The United States Department of Health and Human Services, nor the United States government.

Injuries and Falls from Immobility
Title Description
“CMS Improves Patient Safety for Medicare and Medicaid by Addressing Never Events” (U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services [CMS]) CMS publication. Fact sheet covering new Medicare and Medicaid payment and coverage policies to improve safety for hospitalized patients, including the initiation of new proceedings for “wrong surgery,” a category of “never events.”
“Serious Reportable Events: Transparency, Accountability Critical to Reducing Medical Errors and Harm” (National Quality Forum) In 2002, NQF endorsed a list of Serious Reportable Events (SREs) to increase public accountability and consumer access to critical information about healthcare performance. In 2006, NQF updated the list of SREs. There are 28 events and each is classified under one of six categories: surgical, product or device, patient protection, care management, environment, or criminal. The fact sheet includes a list of the 2006 SREs.
“Patient Safety Indicators Resources” (U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality [AHRQ]) User guides, technical specifications, and development materials (such as brochure, link to software, etc.).
“Inpatient Quality Indicators Resources” (AHRQ) User guide, technical specifications, and development materials (such as brochure, link to software, etc.).
“Fall and Injury Prevention,” Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 10 (AHRQ) [PDF, 612KB] Evidence-based handbook for nurses.
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities (AHRQ) Manual designed to assist in providing individualized person-centered care and improving fall care processes and outcomes through education and quality improvement tools.
“Fall Prevention and Management” (U.S. Department of Veterans Affairs, National Center for Patient Safety [NCPS]) Online assessment and guide to a multi-disciplinary approach to falls prevention and management using a systematic assessment for determining risk and recommended interventions.
“2004 Falls Toolkit” (NCPS) Toolkit accompanied by introductory monograph and PowerPoint slide deck.
“Fatal Falls: Lessons for the Future,” Sentinel Event Alert, Issue 14 (The Joint Commission) Topic Library Item. Health care organizations that have experienced sentinel events due to falls have identified the root causes and risk reduction strategies included in this issue. In addition, experts have commented on the events and the related root causes and risk reduction strategies. The Joint Commission offers this information for consideration by hospitals, long-term care facilities, and behavioral health care organizations in their continuing efforts to reduce the risk of falls of their patients, residents, or individuals served.
“Falls Prevention” (Institute for Healthcare Improvement [IHI]) Listing of Mentor Hospitals for falls prevention. Includes a quick reference table to find a mentor with similar demographics to the inquiring hospital.
“Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls” (IHI) Guide can help staff learn to identify the patients at highest risk for sustaining a serious injury from a fall and implement interventions to prevent or mitigate these injuries. Focuses on approaches to reduce physical injury associated with patient falls.
“Injurious Fall Data Collection Tool” (IHI) Use the data collection spreadsheet to analyze and better understand a unit’s or hospital’s last 20 falls that resulted in injury. Track and communicate patterns, issues, and potential interventions.
“Falls Prevention — Shared Tools” (Minnesota Hospital Association [MHA]) Falls prevention best practices resources, shared tools (policies and procedures, assessment tools, self-learning packets, and patient education tools). Case studies of hospital falls prevention pilot projects.
“SAFE from FALLS Call to Action” (MHA) ”SAFE from FALLS” campaign materials; comprehensive roadmap and toolkit.
“Prevention of Hospital Falls: An RWJF National Program” (Robert Wood Johnson Foundation) Synopsis of the work (2006-2007) and key results (2008).
“Fall Prevention in Acute Care Hospitals: A Randomized Trial” (Journal of the American Medical Association) Peer-reviewed journal article evaluating the benefits of hospital-based fall prevention strategies.
“Fall Assessment Tool” (Johns Hopkins Hospital) Fall Risk Assessment Tool; checklist to determine patient fall risk.
“Falls Prevention Virtual Learning Collaborative” (Safer Healthcare Now!) A collection of presentations (audio) that were delivered at the Falls Prevention Learning Collaborative. The Falls Prevention Learning Collaborative is designed for multi-disciplinary teams from acute care, long-term, and home healthcare settings.
“Preventing Falls Among Older Adults” (U.S. Department of Health & Human Services, Centers for Disease Control and Prevention) This compendium of interventions is designed for public health practitioners and community-based organizations, to help them address the problem of falls among older adults. It describes 22 scientifically tested and proven interventions, and provides relevant details about these interventions for organizations who want to implement fall prevention programs.

Case Studies

Case Studies
Title Description
“Preventing Falls and Eliminating Injury at Ascension Health” (IHI) Eight Ascension Health hospitals served as alpha sites in a program to prevent falls and eliminate falls with injury. A nearly 10 percent system-wide reduction in acute care fall rates was achieved by implementing a standardized risk assessment at defined frequencies along with other tailored prevention strategies. Key steps caregivers can take to prevent falls and fall injuries are described.
“Empowering Nurses to Reduce Falls” (Hospitals in Pursuit of Excellence [HPOE]) Case Study – Southeastern Regional Medical Center, Lumberton, NC.
“Call to Stop a Fall” (HPOE) Case Study – Bronson Methodist Hospital, Kalamazoo, MI.
“Focusing on Patients to Reduce Falls” (HPOE) Case Study – Gundersen Lutheran Health System, La Crosse, WI.
“Reducing Falls” (HPOE) Case Study – Mercy Health Center, Oklahoma City, OK.
“Innovations Exchange: Innovations and Quality Tools: Falls Prevention” (AHRQ) A comprehensive collection of 27 innovations and 18 quality tools for fall prevention and reduction.

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