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Posey Nurse Blog

Predicting Injurious Falls in the Hospital Setting: Implications for Practice

In the September 2016 issue of the American Journal of Nursing, Amy Hester PhD, RN; Pao-Feng Tsai PhD, RN;  Mallik Rettiganti PhD, and Anita Mitchell PhD, APRN have published their article, “Predicting Injurious Falls in the Hospital Setting: Implications for Practice.”  The purpose of the research was to determine which patient factors are associated with injurious falls in hospitalized patients.   This was a retrospective study which evaluated a total of 1,369 falls in 1,369 patients.  In this study 27.8% of falls resulted in

AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing

The Agency for Healthcare Research and Quality (AHRQ) has released a new online tool that could help nursing homes who use electronic medical records to manage residents with pressure ulcers.  On-Time Pressure Ulcer Healing will provide clinical reports so staff can understand the number and types of pressure ulcers that have developed and are being treated at the facility in order to make informed treatment decisions to promote timely healing.  The assessment tool guides clinicians to systematically assess residents with pressure ulcers and thus helps less-experienced clinicians a

American Delirium Society and ANA Launch New Website

In collaboration with a work group of delirium experts, the American Delirium Society and ANA website will raise awareness and provide clinicians resources to help prevent, identify and treat this condition.  Delirium may occur at any age but is more common among the elderly.

Free from Harm – Accelerating Patient Safety Improvement

As a follow  up To Err Is Human: Building a Safer Health System that was published in 1999, the National Patient Safety Foundation(NPSF) has released their report on how to combat medical errors. This was funded by a grant from American International Group, Inc. (AIG).  NPSF report purposed the following recommendations:

2016 HAC Reduction Program Results

On December 10, 2015, CMS released their report on the 2016 HAC Program results.  “ In FY 2016, 758 out of 3,308 hospitals subject to the HAC Reduction Program are in the worst performing quartile and will have a one percent payment reduction applied to all Medicare discharges occurring between October 1, 2015 and September 30, 2016.

17 % Decline in Hospital-Acquired Conditions Since 2010

The Agency for Healthcare Research and Quality (AHRQ) report a sustained 17 percent decline in hospital-acquired conditions (HACs) since 2010.  As a result of the reduction in the rate of HACs, they estimate that approximately 790,000 fewer incidents of harm occurred in 2014 than would have occurred if the rate of HACs had remained steady at the 2010 level.  To read the report go to:  

New Joint Commission Campaign to Reduce Readmissions

The Joint Commission has developed two new resources to help health care providers in their efforts to reduce patient readmissions and improve

“To Err Is Human,”

In 1999, an Institute of Medicine report, “To Err Is Human,” documented serious patient safety problems in our health care system. In the intervening years, the Agency for Healthcare Research and Quality (AHRQ) has led the Nation in responding to those issues and improving the safety of health care.  AHRQ is the lead Federal agency charged with improving the safety and quality of America’s health care system.

Sentinel Event Alert Issue 55: Preventing Falls and Fall-Related Injuries in Health Care Facilities

On September 28, 2015, the Joint Commission published their Sentinel Event Alert Issue 55: Preventing falls and fall-related injuries in health care facilities.  This publication provided an  overview of the tools that have been developed through research and quality improvement initiatives, including the Center for Transforming Healthcare's Preventing Falls Targeted Solutions Tool® (TST®).   In the issue it states, “Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission’s Sentinel Event datab

new Preventing Falls Targeted Solutions Tool®(TST®)

The Joint Commission Center for Transforming Healthcare is promoting their new Preventing Falls Targeted Solutions Tool®(TST®).  This tool can help organizations reach their goals in reducing falls.  The Joint Commission also has Targeted Solutions tools for Hand Hygiene, Safe Surgery and Hand-Off Communications.  The NEW Preventing Falls TST® is complimentary to Joint Commission accredited organizations and is separate from accreditation–surveyors do not have access to TST® data.