Leveraging Event Reporting Through Knowledge Support: A Knowledge-Based Approach to Promoting Patient Fall Prevention

Patient falls are a common safety event type that impairs the healthcare quality. Strategies including solution tools and reporting systems for preventing patient falls have been developed and implemented in the U.S. However, the current strategies do not include timely knowledge support, which is in great need in bridging the gap between reporting and learning. In this study, we constructed a knowledge base of fall events by combining expert-reviewed fall prevention solutions and then integrating them into a reporting system. The knowledge base enables timely and tailored knowledge support and thus will serve as a prevailing fall prevention tool. This effort holds promise in making knowledge acquisition and management a routine process for enhancing the reporting and understanding of patient safety events.

[1]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[2]  Lei Hua,et al.  Information Gaps in Reporting Patient Falls: the Challenges and Technical Solutions , 2013, CSHI.

[3]  John R. Clarke,et al.  The Use of Collaboration to Implement Evidence-Based Safe Practices , 2013, Journal of public health research.

[4]  A. Labrique,et al.  Evidence on feasibility and effective use of mHealth strategies by frontline health workers in developing countries: systematic review* , 2015, Tropical medicine & international health : TM & IH.

[5]  Huw Williams,et al.  Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice , 2016 .

[6]  Marita G Titler,et al.  Nurses’ Perceptions of Implementing Fall Prevention Interventions to Mitigate Patient-Specific Fall Risk Factors , 2016, Western journal of nursing research.

[7]  J. O’Donovan,et al.  Controlling Ebola through mHealth strategies. , 2015, The Lancet. Global health.

[8]  Carolyn M Clancy Common Formats Allow Uniform Collection and Reporting of Patient Safety Data by Patient Safety Organizations , 2010, American journal of medical quality : the official journal of the American College of Medical Quality.

[9]  Blackford Middleton,et al.  Fall prevention in acute care hospitals: a randomized trial. , 2010, JAMA.

[10]  P. Pronovost,et al.  What to do With Healthcare Incident Reporting Systems , 2013, Journal of public health research.

[11]  P. Tosey,et al.  How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review. , 2015, The Milbank quarterly.

[12]  Janice M. Morse,et al.  Preventing patient falls : establishing a fall intervention program , 2009 .

[13]  Itziar Larizgoitia,et al.  WHO Efforts to Promote Reporting of Adverse Events and Global Learning , 2013, Journal of public health research.

[14]  Susanne Hempel,et al.  Hospital Fall Prevention: A Systematic Review of Implementation, Components, Adherence, and Effectiveness , 2013, Journal of the American Geriatrics Society.

[15]  R. Conroy,et al.  Adverse events in healthcare: learning from mistakes. , 2015, QJM : monthly journal of the Association of Physicians.