National Healthcare Quality and Disparities Report
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Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (8)
- Chronic Conditions (1)
- Elderly (7)
- Emergency Department (2)
- Evidence-Based Practice (2)
- (-) Falls (14)
- Hospitals (5)
- Injuries and Wounds (3)
- Inpatient Care (2)
- Long-Term Care (1)
- Medication (2)
- Medication: Safety (1)
- Nursing Homes (1)
- Opioids (1)
- Organizational Change (1)
- Pain (1)
- (-) Patient Safety (14)
- Prevention (6)
- Quality Improvement (2)
- Quality of Care (2)
- Risk (5)
- Surveys on Patient Safety Culture (1)
- Teams (1)
- TeamSTEPPS (1)
- Tools & Toolkits (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 14 of 14 Research Studies DisplayedLeland NE, Lekovitch C, Martínez J
Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.
The purpose of this scoping review was to describe the evidence for multifactorial post-acute care (PAC) fall prevention interventions for older patients. The researchers included 33 studies and characterized common intervention domains including: evaluating patient-specific fall risk factors, developing an individualized risk profile and treatment plan that targets each patient's fall risk factors, and implementing facility-based strategies such as staff education. There was not consensus across studies in how the domains were addressed and to what extent. The researchers concluded that health system efforts to prevent accidental falls in PAC should consider a patient-centered multifactorial approach.
AHRQ-funded; HS022907.
Citation: Leland NE, Lekovitch C, Martínez J .
Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.
J Appl Gerontol 2022 Oct;41(10):2187-96. doi: 10.1177/07334648221104375..
Keywords: Elderly, Falls, Prevention, Patient Safety, Evidence-Based Practice
Chen C, Winterstein AG, Lo-Ciganic WH
Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older US Medicare beneficiaries with chronic noncancer pain: a population-based cohort study.
This study compared the risk of fall-related injury in two cohorts who used gabapentinoids concurrently with opioid use and those who used opioids only. The authors created 2 cohorts based on whether concurrent users initiated gabapentinoids on the day of opioid initiation (Cohort 1) or after opioid initiation (Cohort 2). Both cohorts were identified from a sample of older Medicare beneficiaries with chronic non-cancer pain (CNCP). Four concurrent users were matched up with 1 opioid-only user. They identified 6,733 concurrent users and 27,092 matched opioid-only users in Cohort 1 and 5,709 concurrent users and 22,388 matched opioid-only users in Cohort 2. Cohort 1’s incidence rate of fall-related injury was 24.5 per 100 person-users during follow-up and was 18.0 per 100-person-years during follow-up for Cohort 2. Concurrent users had had similar risk of fall-related injury as opioid-only users in Cohort 1 but had higher risk for fall-related injury than opioid-only users in Cohort 2.
AHRQ-funded; HS027230.
Citation: Chen C, Winterstein AG, Lo-Ciganic WH .
Concurrent use of prescription gabapentinoids with opioids and risk for fall-related injury among older US Medicare beneficiaries with chronic noncancer pain: a population-based cohort study.
PLoS Med 2022 Mar;19(3):e1003921. doi: 10.1371/journal.pmed.1003921..
Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Falls, Patient Safety, Injuries and Wounds, Pain, Chronic Conditions
Dykes PC, Khasnabish S, Burns Z
Development and validation of a fall prevention efficiency scale.
This study examined nurses’ perception of implementing the Fall TIPS (Tailoring Interventions for Patient Safety) tool, which is an evidence-based fall prevention program which was shown to reduce falls in hospitalized adults by 25%. The authors conducted a 3-phase mixed method study at 3 hospitals in Massachusetts and 3 in New York to assess nurses’ perceptions of burdens imposed on them by using Fall TIPS or other fall prevention programs. A 20-item prototype Fall Prevention Efficiency Scale was developed and administered to 383 clinical nurses. This scale was reduced to 13 items. The scale achieved excellent internal consistency values when examined with the test, validation, and paired (both test and retest) samples.
AHRQ-funded; HS025128.
Citation: Dykes PC, Khasnabish S, Burns Z .
Development and validation of a fall prevention efficiency scale.
J Patient Saf 2022 Mar 1;18(2):94-101. doi: 10.1097/pts.0000000000000811..
Keywords: Falls, Prevention, Patient Safety, Hospitals
Venema 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
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.
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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.
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Keywords: Adverse Events, Falls, Hospitals, Patient Safety, Prevention