National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (10)
- Dementia (1)
- Elderly (9)
- Emergency Department (2)
- Evidence-Based Practice (1)
- (-) Falls (18)
- Health Information Technology (HIT) (1)
- Hospitals (5)
- Injuries and Wounds (3)
- Inpatient Care (2)
- Long-Term Care (1)
- Medical Errors (1)
- Medication (2)
- Medication: Safety (1)
- Neurological Disorders (2)
- Nursing Homes (2)
- Organizational Change (1)
- Patient-Centered Outcomes Research (1)
- (-) Patient Safety (18)
- Prevention (4)
- Quality Improvement (2)
- Quality of Care (2)
- Risk (7)
- Shared Decision Making (1)
- Surveys on Patient Safety Culture (1)
- Teams (1)
- TeamSTEPPS (1)
- Tools & Toolkits (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 18 of 18 Research Studies DisplayedVenema DM, Skinner AM, Nailon R
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals.
AHRQ-funded; HS021429.
Citation: Venema DM, Skinner AM, Nailon R .
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
BMC Geriatr 2019 Dec 11;19(1):348. doi: 10.1186/s12877-019-1368-8..
Keywords: Falls, Injuries and Wounds, Patient Safety, Elderly, Risk, Hospitals, Adverse Events
Allen JA, Reiter-Palmon R, Kennel V, et al.
Group and organizational safety norms set the stage for good post-fall huddles.
In this study, the investigators explored group and organizational safety norms as antecedents to meeting leader behaviors and achievement of desired outcomes in a special after-action review case-a post-fall huddle. Findings indicated that organizational and group safety norms related to perceived huddle meeting effectiveness through appropriate huddle leader behavior in a partial mediated framework.
AHRQ-funded; HS024630; HS021429.
Citation: Allen JA, Reiter-Palmon R, Kennel V, et al..
Group and organizational safety norms set the stage for good post-fall huddles.
J Leadersh Organ Stud 2019 Nov;26(4):465-75. doi: 10.1177/1548051818781820..
Keywords: Adverse Events, Falls, Organizational Change, Patient Safety
Jones KJ, Skinner A, Venema D
Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.
Researchers evaluated the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure. They found that multiteam systems that effectively coordinate fall-risk-reduction processes may improve the capacity of hospitals to manage the complex patient, environmental, and system factors that result in falls.
AHRQ-funded; HS024630; HS021429.
Citation: Jones KJ, Skinner A, Venema D .
Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.
Health Serv Res 2019 Oct;54(5):994-1006. doi: 10.1111/1475-6773.13186..
Keywords: Falls, Hospitals, Inpatient Care, Quality of Care, Quality Improvement, Patient Safety, Prevention, Risk
Jones KJ, Crowe J, Allen JA
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
The purpose of this study was to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture. The investigators concluded that post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles were likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.
AHRQ-funded; HS024630; HS021429.
Citation: Jones KJ, Crowe J, Allen JA .
The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project.
BMC Health Serv Res 2019 Sep 9;19(1):650. doi: 10.1186/s12913-019-4453-y..
Keywords: TeamSTEPPS, Falls, Adverse Events, Surveys on Patient Safety Culture, Patient Safety, Hospitals, Teams
Klock M, Kang H, Gon Y
Scoring patient fall reports using quality rubric and machine learning.
Employing AHRQ’s rubric for assessing the quality of fall reports, the authors compared three different machine-learning models and identified the most effective method for scoring fall reports. They intend that their study results will be applicable in healthcare facilities to score reports during reporting for reporters to improve report quality. Their ultimate goal is to increase learning from fall reports for better prevention of patient falls.
AHRQ-funded; HS022895.
Citation: Klock M, Kang H, Gon Y .
Scoring patient fall reports using quality rubric and machine learning.
Stud Health Technol Inform 2019 Aug 21;264:639-43. doi: 10.3233/shti190301..
Keywords: Falls, Patient Safety, Prevention, Quality of Care, Quality Improvement
Patterson BW, Jacobsohn GC, Shah MN
Development and validation of a pragmatic natural language processing approach to identifying falls in older adults in the emergency department.
This study examined development and validation of a pragmatic natural language processing (NLP) approach to identify fall risk in older adults after emergency department (ED) visits. A single center retrospective review using data from 500 emergency department provider notes on older adults age 65 and older were random selected for analysis. The NLP algorithm successfully identified falls in ED notes with over 90% precision, and looks promising to reduce labor-intensive manual abstraction.
AHRQ-funded; HS024558.
Citation: Patterson BW, Jacobsohn GC, Shah MN .
Development and validation of a pragmatic natural language processing approach to identifying falls in older adults in the emergency department.
BMC Med Inform Decis Mak 2019 Jul 22;19(1):138. doi: 10.1186/s12911-019-0843-7..
Keywords: Adverse Events, Elderly, Emergency Department, Falls, Risk, Patient Safety
Patterson BW, Engstrom CJ, Sah V
Training and interpreting machine learning algorithms to evaluate fall risk after emergency department visits.
This study examined the potential of using machine learning algorithms to evaluate fall risk after an emergency department (ED) visit. They compared several machine learning methodologies for creation of a risk stratification algorithm to predict the outcome of a return visit for a fall within 6 months of an ED visit.
AHRQ-funded; HS024558; HS024342.
Citation: Patterson BW, Engstrom CJ, Sah V .
Training and interpreting machine learning algorithms to evaluate fall risk after emergency department visits.
Med Care 2019 Jul;57(7):560-66. doi: 10.1097/mlr.0000000000001140..
Keywords: Adverse Events, Elderly, Emergency Department, Falls, Risk, Patient Safety
Aspinall SL, Springer SP, Zhao X
Central nervous system medication burden and risk of recurrent serious falls and hip fractures in Veterans Affairs nursing home residents.
This study investigated the association between taking central nervous system (CNS) medications with the risk of serious falls and hip fractures. Study participants were residents at a Veterans Health Administration (VHA) Community Living Center (CLC) between July 1, 2005 and June 30, 2009. This was a nested case-control study. The investigators concluded that there was a higher risk in those residents receiving 3.0 or more daily CNS medications.
AHRQ-funded; HS023779.
Citation: Aspinall SL, Springer SP, Zhao X .
Central nervous system medication burden and risk of recurrent serious falls and hip fractures in Veterans Affairs nursing home residents.
J Am Geriatr Soc 2019 Jan;67(1):74-80. doi: 10.1111/jgs.15603..
Keywords: Elderly, Falls, Injuries and Wounds, Long-Term Care, Medication, Nursing Homes, Patient Safety, Risk
Hignett S, Wolf L, Taylor E
Firefighting to innovation: using human factors and ergonomics to tackle slip, trip, and fall risks in hospitals.
The aim of this study was to use a theoretical model (bench) for human factors and ergonomics (HFE) and a comparison with occupational slips, trips, and falls (STFs) risk management to discuss patient STF interventions (bedside). : Three case studies are used to discuss how HFE has been, or could be, applied to STF risk management.
AHRQ-funded; HS021824.
Citation: Hignett S, Wolf L, Taylor E .
Firefighting to innovation: using human factors and ergonomics to tackle slip, trip, and fall risks in hospitals.
Hum Factors 2015 Nov;57(7):1195-207. doi: 10.1177/0018720815593642.
.
.
Keywords: Patient Safety, Risk, Falls, Hospitals
Callaghan B, Kerber K, Langa KM
Longitudinal patient-oriented outcomes in neuropathy: importance of early detection and falls.
This study evaluated longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis. It concluded that, in older persons, differences in falls, pain, and self-rated health can be detected 3–5 years prior to peripheral neuropathy diagnosis, but only falls deteriorate more rapidly over time in neuropathy cases compared to controls.
AHRQ-funded; HS017690; HS022258.
Citation: Callaghan B, Kerber K, Langa KM .
Longitudinal patient-oriented outcomes in neuropathy: importance of early detection and falls.
Neurology 2015 Jul 7;85(1):71-9. doi: 10.1212/wnl.0000000000001714..
Keywords: Patient-Centered Outcomes Research, Neurological Disorders, Falls, Elderly, Patient Safety
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.
.
.
Keywords: Adverse Events, Falls, Shared Decision Making, Medical Errors, Patient Safety
Su BY, Ho KC, Rantz MJ
Doppler radar fall activity detection using the wavelet transform.
The authors propose the use of Wavelet transform (WT) to detect human falls using a ceiling mounted Doppler range control radar. Evaluations based on the data collected in the lab, in the bathrooms, and in the senior residence apartment validate the promising and robust performance of the proposed WT fall activity detector.
AHRQ-funded; HS018477.
Citation: Su BY, Ho KC, Rantz MJ .
Doppler radar fall activity detection using the wavelet transform.
IEEE Trans Biomed Eng 2015 Mar;62(3):865-75. doi: 10.1109/tbme.2014.2367038..
Keywords: Falls, Patient Safety, Adverse Events
Stone E, Skubic M, Rantz M
Average in-home gait speed: investigation of a new metric for mobility and fall risk assessment of elders.
This study assessed how a new metric, average in-home gait speed (AIGS), measured using a low-cost, continuous, environmentally mounted monitoring system, compares to a set of traditional physical performance instruments used for mobility and fall risk assessment of elderly adults. It found that, using the ability of an instrument to predict how an individual would score on all the instruments as a metric, AIGS performs best, having better predictive ability than the traditional instruments.
AHRQ-funded; HS018477.
Citation: Stone E, Skubic M, Rantz M .
Average in-home gait speed: investigation of a new metric for mobility and fall risk assessment of elders.
Gait Posture 2015 Jan;41(1):57-62. doi: 10.1016/j.gaitpost.2014.08.019..
Keywords: Patient Safety, Falls, Elderly, Risk
Aspinall SL, Zhao X, Semia TP
Epidemiology of drug-disease interactions in older veteran nursing home residents.
The objective of this study was to assess the prevalence of and factors associated with potentially inappropriate drug– disease combinations according to the AGS 2012 Beers criteria that are clinically important in elderly adults residing in Veterans Affairs Community Living Centers. It found that drug-disease interactions were common in older residents with dementia or cognitive impairment or a history of falls or hip fracture.
AHRQ-funded; HS018721.
Citation: Aspinall SL, Zhao X, Semia TP .
Epidemiology of drug-disease interactions in older veteran nursing home residents.
J Am Geriatr Soc 2015 Jan;63(1):77-84. doi: 10.1111/jgs.13197..
Keywords: Adverse Drug Events (ADE), Adverse Events, Dementia, Elderly, Falls, Injuries and Wounds, Medication, Medication: Safety, Neurological Disorders, Nursing Homes, Patient Safety
Stone EE, Skubic M
Fall detection in homes of older adults using the Microsoft Kinect.
The researchers present a method for detecting falls in the homes of older adults using the Microsoft Kinect and a two-stage fall detection system. The method is compared against five state-of-the-art fall detection algorithms and significantly better results are achieved.
AHRQ-funded; HS018477.
Citation: Stone EE, Skubic M .
Fall detection in homes of older adults using the Microsoft Kinect.
IEEE J Biomed Health Inform 2015 Jan;19(1):290-301. doi: 10.1109/jbhi.2014.2312180..
Keywords: Patient Safety, Falls, Elderly, Health Information Technology (HIT)
Waters TM, Chandler AM, Mion LC
Use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify inpatient fall-related injuries.
The researchers compared falls and fall-related injuries that a fall evaluator or hospital incident report identified with injuries identified according to discharge ICD-9-CM codes for the same set of inpatient episodes of care. They found that the CMS-targeted ICD-9-CM codes used to identify fall-related injuries in claims data do not always detect the most-serious falls.
AHRQ-funded; HS020627.
Citation: Waters TM, Chandler AM, Mion LC .
Use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify inpatient fall-related injuries.
J Am Geriatr Soc 2013 Dec;61(12):2186-91. doi: 10.1111/jgs.12539..
Keywords: Falls, Elderly, Patient Safety, Inpatient Care, Adverse Events
Clancy CM
AHRQ Author: Clancy CM
Evidence-based toolkit helps organizations reduce patient falls.
This article describes an evidence-based hospital fall-prevention toolkit developed by AHRQ that helps clinicians negotiate the change process at their organization. It was created by a team with expertise both in fall prevention and in organizational change, including staff from the RAND Corporation, ECRI Institute, and Boston University.
AHRQ-authored.
Citation: Clancy CM .
Evidence-based toolkit helps organizations reduce patient falls.
J Nurs Care Qual 2013 Jul-Sep;28(3):195-7. doi: 10.1097/NCQ.0b013e318294a9d1.
.
.
Keywords: Evidence-Based Practice, Falls, Tools & Toolkits, Patient Safety, Prevention
Hempel S, Newberry S, Wang Z
AHRQ Author: Spector WD
Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness.
The authors sought to document systematically the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals. They found that most interventions included multiple components, and the pooled postintervention incidence rate ratio (IRR) was 0.77. They found no systematic association between implementation intensity, intervention complexity, comparator information, or adherence levels and IRR. They concluded that promising approaches exist, but better reporting of outcomes, implementation, adherence, intervention components, and comparison group information is necessary to establish evidence on how hospitals can successfully prevent falls.
AHRQ-authored; AHRQ-funded; 290201000017I.
Citation: Hempel S, Newberry S, Wang Z .
Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness.
J Am Geriatr Soc 2013 Apr;61(4):483-94. doi: 10.1111/jgs.12169.
.
.
Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention