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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
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1 to 2 of 2 Research Studies DisplayedDykes PC, Duckworth M, Cunningham S
Pilot testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.
Patient falls during an acute hospitalization cause injury, reduced mobility, and increased costs. The laminated paper Fall TIPS Toolkit (Fall TIPS) provides clinical decision support at the bedside by linking each patient's fall risk assessment with evidence-based interventions. The investigators examined strategies to integrate this evidence into clinical practice. They concluded that engaging hospital and clinical leadership is critical in translating evidence-based care into clinical practice. They address and detail barriers to adoption of the protocol to provide guidance for spread to other institutions.
AHRQ-funded; HS025128.
Citation: Dykes PC, Duckworth M, Cunningham S .
Pilot testing Fall TIPS (Tailoring Interventions for Patient Safety): a patient-centered fall prevention toolkit.
Jt Comm J Qual Patient Saf 2017 Aug;43(8):403-13. doi: 10.1016/j.jcjq.2017.05.002..
Keywords: Clinical Decision Support (CDS), Shared Decision Making, Evidence-Based Practice, Falls, Hospitals, Injuries and Wounds, Inpatient Care, Patient Safety, Prevention, Risk, Tools & Toolkits
Reiter-Palmon R, Kennel V, Allen JA
Naturalistic decision making in after-action review meetings: the implementation of and learning from post-fall huddles.
In this study, the authors added to our understanding of Naturalistic Decision Making (NDM) in healthcare and how After Action Reviews (AARs) can be utilized as a learning tool to reduce errors. They found that the use of self-guided post-fall huddles increased over the time of the project, the types of errors identified as contributing to the patient fall changed, and the proportion of falls with less adverse effects increased during the project time period. They concluded that , over time, self-guided AARs can be useful for some aspects of learning from errors.
AHRQ-funded; HS021429.
Citation: Reiter-Palmon R, Kennel V, Allen JA .
Naturalistic decision making in after-action review meetings: the implementation of and learning from post-fall huddles.
J Occup Organ Psychol 2015 Jun;88(2):322-40. doi: 10.1111/joop.12084.
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Keywords: Adverse Events, Falls, Shared Decision Making, Medical Errors, Patient Safety