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This is indicated if the hospitals report different fall rates, i.e., there is a certain degree of variability across the hospitals [11]. In particular, try to determine whether the falls are irregular events (e.g., a patient's first-ever seizure that resulted in a fall) or whether there is a regularity to the types of falls (e.g., related to toileting) that suggest a specific intervention is needed to improve care. The key factors were the aim of the data collection (documentation and development of quality of care), the type of data collected (only data that is also collected as part of the regular nursing process) and the fact that no intervention is carried out. Instead, unit staff members are becoming better at reporting falls that were previously missed. 75. Process - assessment, intervention, and job satisfaction. The data gathered were entered into the web-based data entry program on the LPZ website, which could only be completed after all mandatory questions had been answered in order to avoid missing values. One possible explanation is that from a certain level of care dependency, mobility is so severely restricted that locomotion is no longer possible or only possible when accompanied by caregivers, and therefore the risk of falling is lower. BWH unit compliance with using Fall TIPS averaged 82%, the mean fall rate decreased from 3.28 to 2.80 falls per 1,000 patient-days from January through June 2015 versus 2016, and the mean fall with injury rate for these periods decreased from 1.00 to 0.54 per 1,000 patient-days. Except for the maternity and outpatient wards, all ward types were included in the measurement. Southwest Respir Crit Care Chron. Fung V, Schmittdiel JA, Fireman B, Meer A, Thomas S, Smider N, et al. The overall picture should form the basis for discussion and analysis in the team in order to identify potential quality issues and initiate appropriate preventive measures. National Benchmarks Prepared for: Sample Hospital City, ST Medicare ID: 999999. Content last reviewed January 2013. Some economists now expect the Fed to raise its benchmark rate by a substantial half-percentage point when it meets later this . Remember that fall rates may change based on the season of the year and can be quite different from unit to unit (e.g., geriatric psychiatry unit versus intensive care unit). Dijkstra A. This article describes the development of a model for risk adjustment of inpatient fall rates in acute care hospitals based on patient-related fall risk factors and presents the impact and results of risk adjustment on hospital performance comparison across Swiss acute care hospitals. R: A Language and Environment for Statistical Computing. Three-year operating revenue CAGR: 5.2 percent 7.. After excluding maternity and outpatient wards, all inpatients older than 18years were included. Thereafter, the remaining variability in risk-adjusted fall rates can be attributed to differences in quality of care provided by a hospital. Jana Donovan, RN, Administrator, Hernando Hospice Care Center, 1114 Chatman Blvd., Brooksville, FL 34601. :B(Ul/{}l+`l7Cu 0>OkX"#hu3eG|Meilgl?+ gl2y_Aax D0M3@%R Q:+C Q4HYbWl_#q"M1qZz5T Maturitas. Article PubMed Lane-Fall MB, Neuman MD. Med Care. National average: 6.95% For the week of February 24th, top offers on Bankrate is 0.52% lower than the national average. National Quality Forum. After adjusting for patient-related risk factors, the ICC decreased to 3% in the inpatient fall risk model. Ten or 20 records may be sufficient for initial assessments of performance. Analysis of falls that caused serious events in hospitalized patients. COTH Quarterly Financial Survey and Benchmark Report The data collected via the COTH Quarterly Financial Survey, conducted since 1999, provides critically important information necessary to monitor the financial condition of member teaching hospitals. How are they changing? In 2006, Jan Hasbrouck and Gerald Tindal completed an extensive study of oral . Morello RT, Barker AL, Watts JJ, Haines T, Zavarsek SS, Hill KD, et al. Archives of Gerontology and Geriatrics. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. https://doi.org/10.1016/j.jgo.2014.10.003. Wickham H. ggplot2: Elegant Graphics for Data Analysis. Nevertheless, in order to enable a fair comparison of hospital performance, especially when comparing on the national level and including different hospital types, the presence of patient-related fall risk factors in patient populations must be considered, as patients are not randomly allocated to hospitals and can therefore vary considerably from hospital to hospital [26]. Patient-related fall risk factors such as care dependency, history of falls and cognitive impairment should be routinely assessed. https://doi.org/10.18637/jss.v067.i01. Background: Comparing inpatient fall rates can serve as a benchmark for quality improvement. To test for a possible measurement year effect, we recalculated the initial risk-adjusted model by including the measurement year as a control variable. Accordingly, all patients received an information letter before the measurement explaining the aim and purpose of the quality measurement. The central bank's benchmark rate is now in a range of 4.5% to 4.75%, its highest . Hekkert, Kool [67] reported even smaller ICC values of 0.5% to 2.7% at hospital level for readmission rates after different surgical procedures. Falls among adult patients hospitalized in the United States: prevalence and trends. Prevention efforts begin with assessing individual patients' risk for falls. Goal The goal is to reduce harm from falls to one (or less) per 10,000 patient days. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Good performance on these key processes of care is critical to preventing falls. https://doi.org/10.1186/s12913-022-07638-7, DOI: https://doi.org/10.1186/s12913-022-07638-7. At the national level, since the variability always refers to the average of all hospitals, no statement can be made as to whether good or bad quality is achieved in Swiss hospitals regarding inpatient falls in general. Fifth, an initial risk-adjusted multilevel logistic regression model (risk-adjusted model) was developed that incorporates the patient-related fall risk factors found in step four by using fixed effects, and the grouping variable hospital as a random effect. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. The injurious fall rate can be tracked just like the total fall rate. https://doi.org/10.1016/j.apnr.2014.12.003. https://doi.org/10.5334/irsp.90. 2019;27(5):10119. g The overall participation rate was 75.1%. Care dependency was measured by the Care Dependency Scale (CDS) [32]. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. PubMedGoogle Scholar. All benchmarks and statistics on this list are averages gathered by compiling data from multiple ASCs. PC}T? Fall prevention is a National Patient Safety Goal for both hospitals and long-term care facilities. For a general overview of how to collect and use data for quality improvement: Needham DM, Sinopoli DJ, Dinglas VD, et al. Larger gifts ($1,000 or more) increased by 10.4%, while mid-level gifts ($250 to $999) improved by 8.0%. Google Scholar. When you first implement a quality improvement program and begin tracking performance, increased fall rates are frequently seen. 2012;2012:606154. https://doi.org/10.1100/2012/606154. More than 2.7% of the 7.4 million people admitted to acute care hospitals in the UK in 2015/2016 experienced a fall incident, which, converted into international dollars according to the Organisation for Economic Co-operation and Development (OECD) [8], led to total annual costs for UK acute care hospitals of around $739 million [7]. Non-participation had no negative consequences for the patients. We recommend that you regularly monitor: (1) an outcome (such as falls per 1,000 occupied bed days), (2) at least one or two care processes (e.g., assessment of fall risk factors and actions taken to reduce fall risk), and (3) key aspects of the infrastructure to support best practices (e.g., checking for interdisciplinary participation in Implementation Team). 2016. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. 91%. This might include mention of the patient's level of orientation and cognition, gait and balance, continence status, and number and types of prescribed medications, as well as number of diagnoses. Each approach has its strengths and limitations: As a starting point, we recommend that you combine medical record review with direct observation using a manageable sample size (e.g., no more than 20 patients), as suggested in Tool 5B. Risk adjustment attempts to control for patient-related risk factors that cannot be influenced by care, so that the remaining variability in risk-adjusted fall rates can be attributed with some certainty to differences in the quality of care provided by hospitals. To count falls properly, people in your hospital or hospital unit need to agree on what counts as a "fall." No hospital had a lower risk-adjusted inpatient fall rate (high-performing hospital) than the overall average. Additionally, three statistically significant protective factors, i.e., factors that reduce the risk of an inpatient fall, were also selected into the model. Q3 CY 2020. In Switzerland, all acute care hospitals that have joined the national quality contract (approximately 97% of Swiss acute care hospitals) participated in the survey. In late 2016 the NPA Board of Directors charged the NPA Data Team with the task of improving the abilities, capacities and meaningfulness of NPA benchmark reporting through the PACE Quantum initiative. There are two overarching considerations in planning a fall prevention program. First, count the number of falls that occurred during the month of April from your incident reporting system. The data was collected pseudonymously to prevent possible conclusions about the identity of the patients. Nevertheless, it is a moot point whether the consideration of this variable in the risk adjustment model is appropriate due to the procedural character of the variable. 2014;70(11):246982. Template matching for benchmarking hospital performance in the veterans affairs healthcare system. This dashboard details the extent of harm due to falls, the presence of fall assistance, presence of fall assistance by patient harm, type of fall injury, and fall location. JS contributed to the conceptualization, interpretation of results, writing, reviewing, and editing of the manuscript. DR contributed to the conceptualization, supervision and validation of the statistical analysis, interpretation of results, writing, reviewing, and editing of the manuscript. In our analysis, however, it was not possible to adjust for these factors as they were not collected in our measurements. Medical-Surgical: 3.92 falls/1,000 patient days. Overview of predictors included in the inpatient fall risk adjustment model and their corresponding odds ratios. Note for the grayed-out states on the 2012 map: In the 2012 BRFSS survey, Michigan, Oregon, and Wisconsin used a different falls question from the rest of the states. Venables WN, Ripley BD. Common general surgical never events: analysis of NHS England never event data. Q3 2022 Rate of Patient Falls: 0.151 per 1000 admissions: Represents 2,233,425 ASC admissions seen at 1,939 ASCs between July 1, 2022 and September 30, 2022. For inpatients in acute care hospitals falls are one of the most frequently reported safety accidents [5,6,7]. This Primer will focus on fall prevention in health care facilities, because these are generally placed under the umbrella of health careassociated harms. A basic principle of quality measurement is: If you can't measure it, you can't improve it. Finally, CMS determined that 95.8% of residents had their activities of daily living (ADLs) and thinking skills recorded in their treatment plans, along with related goals. This may also be true for the ICD-10 diagnosis group Neoplasms as there is evidence that, in addition to the established general patient-related fall risk factors, cognitive impairment, metastases, especially brain metastases, but also comorbidities such as anaemia or fatigue are specific fall risk factors in cancer care [55, 60]. Think about what you have or have not been doing well over the past months and relate it to whether the fall rate is getting better or worse. Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. To ensure that the information is available on the day of the measurement, nurses are required to document all falls during the 30days prior to the measurement (Fachhochschule B: Messhandbuch Schweiz - Nationale Prvalenzmessung Sturz und Dekubitus 2019 im Rahmen der Internationalen Prvalenzmessung von Pflegequalitt, LPZ International, Unpublished). benchmarks, or standards against which to judge performance, for value-based payment programs. bJ*$,h(TT NwQMz%fi6XrJ3Zgt*s2.9@1e6`,B-J If not, you will need to choose a point in time each day that is convenient to check the number of occupied beds on your unit, and write down that number each day, to be tallied as explained below. with Nurses" displays the percent of patients who reported that their nurses "Always" communicated well. Performance of fall risk factor assessment within 24 hours of admission. The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. SH supervised the project and contributed to the acquisition, conceptualization, interpretation of results, writing, reviewing, and editing of the manuscript. et al. Intensive Care Unit: 1.30 falls/1,000 patient days. Defining a fall is especially a problem in "borderline" cases, such as when a patient feels her knees giving out while walking with a hospital staff member and the staff member eases the patient onto the floor. 2008;54(6):3428. The inpatient fall rates found range from 1 to 17% [12,13,14,15,16]. For the analysis of the variability of the hospital effects we extracted the residuals of the hospitals and their 95% confidence intervals from the fitted models by using the method proposed by Rabe-Hesketh and Skrondal [48] and plotted them in a ranked order in a caterpillar plot. Policy, U.S. Department of Health & Human Services. These benchmarks will apply to Shared 2014;20(4):396400. Trends and Benchmarks Resources Annual response rate to the survey is 78%. 5600 Fishers Lane The number of cases is too small . Nakagawa S, Schielzeth H. A general and simple method for obtaining R2 from generalized linear mixed-effects models. 2017;120:915. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. Journal of Patient Safety. For example, the literature describes that cognitive impairment is associated with a higher risk of falling [19, 20, 22, 55, 59]. Plotting basic control charts: tutorial notes for health care practitioners. All authors read and approved the final manuscript. hb```7@r03!$01x%0c(= ac'$$3,M``1QA.A7q.~ #9f3,2:222:2=~y&BX T)\;05)w4{cGKFKD[{4)uD]F(56hP(1.B6z4P/- @@hF7'x Standard data structures for incident reports may be found in the resource box in section 5.1.4. 2019;8(5):3006. Dunne TJ, Gaboury I, Ashe MC. Therefore, the initial risk adjusted model was subsequently reported. Agency for Healthcare Research and Quality, Rockville, MD. Does root cause analysis improve patient safety? 2005;3 Suppl 1(Suppl 1):S5260. Google Scholar. IEEE Trans Autom Control. Rev Latino-Am Enferm. Medicine. A Dijkstra J Smith M White Manual Care Dependency Scale. There is no single "right" approach to measuring fall rates. The LPZ instrument in its basic version was psychometrically tested, particularly with regard to the quality of care indicator pressure ulcers, and was assessed as being reliable and valid [36,37,38]. Approximately one-fourth of inpatient falls are injurious [ 3 ], with estimated costs exceeding $7000 per injury [ 4 ]. (https://CRAN.R-project.org/package=sjPlot). Send reports to leadership. The null-model served afterwards as a reference model in three respects: (1) to assess the outcome heterogeneity between hospitals measured by the Intraclass Correlation Coefficient (ICC) [42]; (2) to compare the model fit of the subsequent risk-adjusted model; (3) to visualize the unadjusted hospital performance in a caterpillar plot and, therefore, to detect low- and high-performing hospital outliers if no risk adjustment was undertaken. PSI 10 - Postoperative Acute Kidney Injury Requiring Dialysis Rate, per 1,000 Admissions . 122/11). Participation in the measurement was voluntary. These include direct observations of care, surveys of staff, and medical record reviews. IE contributed to the conceptualization, interpretation of results, writing, reviewing, and editing of the manuscript. Thomann S, Rsli R, Richter D, Bernet NS. Burnham KP, Anderson DR. Multimodel Inference: Understanding AIC and BIC in Model Selection. We did not include these factors in our risk adjustment model because that are exactly the factors which are under the control of the hospital and thus differentiate between hospitals. Sommet N, Morselli D. Keep calm and learn multilevel logistic modeling: A simplified three-step procedure using Stata, R, Mplus, and SPSS. It contains three questionnaires related to three levels: an institutional, a ward and a patient questionnaire. Data are however available from the authors upon reasonable request and with permission of the Swiss National Association for Quality Development in Hospitals and Clinics (ANQ). One of the nurses works on the ward in question and the other works in a different ward [29]. To analyze data on rare events, such as injurious falls, learn about the g-type control chart in Benneyan JC. Thank you for taking the time to confirm your preferences. Therefore, we can conclude that Swiss hospitals, regardless of hospital type, show a comparable level of care quality with respect to inpatient falls, after adjusting for patient-related fall risk factors. https://doi.org/10.1370/afm.340. Therefore, consider reviewing completed incident reports with staff on a monthly basis. In total, 1,239 participants experienced an inpatient fall, corresponding to a fall rate of 3.4% (95% CI=3.3%-3.6%) across all hospitals in Switzerland. Most falls occur in elderly patients, especially those who are experiencing delirium, are prescribed psychoactive medications such as benzodiazepines, or have baseline difficulties with strength, mobility, or balance. PubMed AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. PubMed This applies in principle to all risk factors in the model. Accessed 01 June 2021. endstream endobj 1518 0 obj <>stream BMC Health Serv Res. For example, if a patient is noted to be disoriented, is there an assessment for delirium (go to. They help us to know which pages are the most and least popular and see how visitors move around the site. endstream endobj 1513 0 obj <>/Metadata 85 0 R/OCProperties<>/OCGs[1522 0 R]>>/Outlines 97 0 R/PageLayout/SinglePage/Pages 1504 0 R/StructTreeRoot 160 0 R/Type/Catalog/ViewerPreferences<>>> endobj 1514 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageC]/Properties<>/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1515 0 obj <>stream We demonstrated that adjusting for these factors has a relevant impact on the results of hospital performance comparison, as it reduces the number of low as well as high-performing hospitals. Surgical: 2.79 falls/1,000 patient days. Outcomes measures and risk adjustment. Internet Citation: Falls Dashboard. The AHRQ Common Formats Web site also links to a standard structure for collecting data for a fall-related incident report: https://www.psoppc.org/web/patientsafety/version-1.2_documents#Fall . National Partnership for Maternal Safety: consensus bundle on support after a severe maternal event. (https://ggplot2.tidyverse.org). The impact of the inclusion of these other factors on the accuracy of the risk adjustment model should be further investigated. 1987;34(Supplement 4):124. More than three quarters of the patients were either completely care independent (53.5%, n=19,247) or to a great extent care independent (24.5%, n=8,807). The development of a national registration form to measure the prevalence of pressure ulcers in the Netherlands. Number-between g-type statistical quality control charts for monitoring adverse events. https://doi.org/10.1159/000129954. Summary of HCAHPS Survey Results Table. https://doi.org/10.1002/jcsm.12411. H\j@LA?0;/y Yx$o9sB With odds ratios between 1.26 and 0.67, eight further ICD-10 diagnosis groups were included. The patient questionnaire is divided into two parts. PubMed Bates D, Mchler M, Bolker B, Walker S. Fitting Linear Mixed-Effects Models Using lme4. ONeil CA, Krauss MJ, Bettale J, Kessels A, Costantinou E, Dunagan WC, et al. Fall deaths in 2015 increased by 6,000 as compared to the previous year. Generate an incident report for every fall that occurs. https://doi.org/10.1038/nmeth.3968. nezh la0 H3pti> g Q _< Sci Rep. 2018;8(1):10261. https://doi.org/10.1038/s41598-018-28101-w. The red dots indicate hospitals with significantly higher inpatient fall rates compared with the overall average. Objective: The goal of this study was to estimate the incidence of falls (total, injurious, and assisted) in U.S. psychiatric care across 6 years (April 2013-March 2019). 3rd ed. The 95% interval estimate surrounding the hospital's rate includes the national rate. IQI 19 Hip Fracture Mortality Rate, per 1,000 Admissions IQI 20 Pneumonia Mortality Rate, per 1,000 Admissions IQI 21 Cesarean Delivery Rate - Uncomplicated, per 1,000 Admissions IQI 22 Vaginal Birth After Cesarean (VBAC) Delivery Rate - Uncomplicated, per 1,000 Admissions AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Inpatient falls are considered to be a nursing-sensitive quality of care indicator, as they are healthcare-acquired, mostly preventable and, as described, have serious consequences for patients, hospitals and the health care system [3, 9]. Journal of Hospital Medicine. During this time the coronavirus ( COVID-19 . Manage cookies/Do not sell my data we use in the preference centre. Death rate for heart attack patients: 12.9 . Approximately half of the 1.6 million nursing home residents in the United States fall each year, and a 2014 report by the Office of the Inspector General found that nearly 10% of adverse events experienced by Medicare skilled nursing facility residents were falls resulting in significant injury. Ambrose AF, Cruz L, Paul G. Falls and Fractures: A systematic approach to screening and prevention. For risk factor assessment to make a difference, all risk factors identified on the risk factor assessment need to be addressed in the care plans, and the care plans need to be acted on. The ICD-10 group diagnoses were important to account for relevant comorbidities in the risk adjustment model. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Nevertheless, care should be taken in further fall measurements to take the temporal relation into account if possible. Sometimes staff would like to simply track the number of falls that occur every month or every quarter on a given unit. Since we carried out data-driven statistical variable selection in our model development, it is particularly important to critically review the selected risk variables. You can also build a form based on the postfall assessment form for root cause analysis (Tool 3O) in this toolkit. A 2011 PSNet perspective discussed the specific components most often used in successful fall prevention interventions. When looking at hospital types separately, university hospitals had the highest inpatient fall rates (3.8%, 95% CI=3.3%-4.2%), followed by general hospitals (3.4%, 95% CI=3.2%-3.6%) and specialised clinics (3.2%, 95% CI=2.5%-3.9%). The National Quality Forum [3] write in their technical report, unfortunately without giving the actual figures, that the ICC of inpatient falls is higher at ward level than at hospital level. HyTTw}qpKbjDtPQ (''$Gcb&Fcj(E\b jLs~wy}{?4:[]i}UY3s3 sA>5@h%xj9 g,G Q-1]=3_!eVl~=7Q\3'3][G2ZIw[P2r*mI;`3?p^n(~L("eF ( Falls are the most . Take a sample of records of patients newly admitted to your unit within the past month. One study, using data from the National Database of Nursing Quality Indicators, found that fall rates varied substantially across units: Intensive Care Unit: 1.30 falls/1,000 patient days. An additional search on CINAHL with the same search terms yielded no further relevant results. Part of 2015;28(2):7882. Email: FFFAP@rcp.ac.uk. These should include the admission nursing assessment, physician's admission note, and subsequent nursing progress notes. NCPS staff members worked with the Patient Safety Center of Inquiry, Tampa, Fla ., and others to develop the Falls Toolkit. However, there are only a limited number of general, well-researched patient-related fall risk factors such as advanced age, history of falls, cognitive impairment, the use of psychotropic medication and impaired gait, balance and or mobility [19, 20]. Organisation for Economic Co-operation and Development (OECD). Kellogg International Work Group on the Prevention of Falls by the Elderly. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. 4. Include falls when a patient lands on a surface where you wouldn't expect to find a patient. While we make specific recommendations below, the most important point is to be consistent. It should be noted that inpatient falls can also be influenced by structural factors at the department level, such as environmental (e.g., floors, lighting [55]) or organizational features (e.g., skill mix, nurse staffing ratio [71, 72]). https://doi.org/10.1111/jep.12144. The best measure of falls is one that can be compared over time within a hospital unit to see if care is improving. https://doi.org/10.1016/j.archger.2012.12.006. Sarcopenia and its association with falls and fractures in older adults: A systematic review and meta-analysis. Agency for Healthcare Research and Quality, Rockville, MD. To ensure uniform data collection, all information about measurement, such as definitions, instructions for completing the questionnaires and technical aids were summarized in a manual (Fachhochschule B. Messhandbuch Schweiz - Nationale Prvalenzmessung Sturz und Dekubitus 2019 im Rahmen der Internationalen Prvalenzmessung von Pflegequalitt, LPZ International, Unpublished), which was available to the hospital coordinators and the measurement teams. ANA has worked closely with the CMS Partnership for Patients to reduced harm from falls; Resources. https://doi.org/10.1111/jocn.13510. Also displayed are the number of participating hospitals and . 2018. https://monashhealth.org/wp-content/uploads/2019/01/Risk-factors-for-falls_Final-27082018.pdf. Death rate for pneumonia patients: 15.6 percent. Go back to section 2.2 for suggestions on how to make needed changes. In accordance with several studies and guidelines [19, 20, 55,56,57,58,59], older age and a fall in the last 12months proved to be a relevant patient-related fall risk factor in our risk adjustment model. Care Dependency, an assessment instrument for use in long-term care facilities. 76. Accessed 14 Dec 2021. Patient Safety 2015. The hospital comparison based on the unadjusted inpatient fall rates revealed 20 low-performing and three high-performing hospitals. \*Wi!Ru+ :eD }$ZyVi3CU Eri&c#vv-V The U.S. Department of Health and Human Services (HHS) released targets for the national acute care hospital metrics for the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination (HAI Action Plan) in October 2016. https://doi.org/10.15171/ijhpm.2019.11. It is likely that differences among patient populations, risk factors, and hospital environmental factors may limit the generalizability of published interventions across hospitals. CAS https://doi.org/10.1136/bmj.h1460. The non-adjusted hospital comparison as a basis for decision-making would result in some hospitals being ranked better or worse than their actual fall rate performance effectively is. An international prevalence measurement of care problems: study protocol.