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Knowledge Repository

Why do patients in acute care hospitals fall? Can falls be prevented?

Author(s): Dykes, P. C., Carroll, D. L., Hurley, A. C., Benoit, A., Middleton, B.
Despite a large quantitative evidence base for guiding fall risk assessment and not needing highly technical, scarce, or expensive equipment to prevent falls, falls are serious problems in hospitals.
Key Point Summary

Applying root cause analysis to improve patient safety: decreasing falls in postpartum women.

Author(s): Chen, K. H., Chen, L. R., Su, S.
The objective of this study was to investigate the effectiveness of interventions to prevent falls designed through hazard analysis using root cause analysis.
Key Point Summary

Exploring Safety and Quality In a Hemodialysis Environment With Participatory Photographic Methods: A Restorative Approach.

Author(s): Marck, P., Molzahn, A., Berry-Hauf, R., Hutchings, L. G., Hughes, S.
The authors indicate that hemodialysis units can be fraught with numerous safety issues related to medication errors, lapses in communication, patient falls, equipment issues, infection control, etc. These issues can be critical in high-acuity units. This study used qualitative methods to identify existing and potential safety issues in a hemodialysis unit in a tertiary care hospital in Canada.
Key Point Summary

Adding additional grab bars as a possible strategy for safer hospital stays

Author(s): Tzeng, H.-M., Yin, C.-Y., Schechtman,S.
Inpatient falls are the most commonly reported incidents in hospitals, yet they are largely avoidable and, therefore, an unsolved issue in patient care. It comes as no surprise that patient falls tend to occur most frequently in patient rooms, patient bathrooms, and hallways—the places in which patients spend the majority of their time during their hospital stay. Falls are attributed to breakdowns in communication between patients and caregivers, inadequate assistance, and also the design of the physical environment.
Key Point Summary

Reducing Falls in a Definitive Observation Unit: An Evidence-Based Practice Institute Consortium Project

Author(s): Gutierrez, F., Smith, K.
A Definitive Observation Unit (DOU) in a hospital in California maintains high standards of nursing and follows an evidence-based practice of fall prevention. Yet the facility’s fall rates continue to be higher than the benchmark for similar hospitals.
Key Point Summary

Designing with health in mind. Innovative design elements can make hospitals safer, more healing places

Author(s): Sadler, B.L.