---
title: "Expanding Adverse Event Reporting to Drive Quality Improvement"
url: https://uprightfallprevention.com/expanding-adverse-event-reporting-drive-quality-improvement/
description: "Upright is a person-centered, comprehensive fall prevention and risk reduction program that utilizes the Hendrich II Fall Risk Model."
published: 2015-11-02
updated: 2015-11-02
---

# Expanding Adverse Event Reporting to Drive Quality Improvement

Published 2015-11-02

Posted on November 2, 2015 by dwana

A statewide advisory committee of the Pennsylvania Patient Safety Authority recently developed a falls reporting program that extended the concept of falls prevention into the realm of quality improvement.1 The resulting Pennsylvania Patient Safety Reporting System (PA-PSRS) uses set definitions of inpatient falls and a falls event decision tree that standardizes falls reporting.2 Hospitals enrolled in the program may access a number of different analytic reports related to inpatient falls from institutions system-wide. A falls dashboard, based on gaps in falls risk assessment processes, and real-time falls outcomes reports, supply data quickly so hospitals can identify areas needing improvement.1,2

A total of 41.3% of hospitals in Pennsylvania enrolled in the program within 6 months of its inception and of these, 82.9% report that the analytic reports were helpful.1 However, the rate of injurious inpatient falls declined less than 1% since introducing the program. Nevertheless, the program’s designers are hopeful that tool will support quality improvement as hospitals adapt to using system-wide data and timely feedback.

1. Gardner LA, Bray PJ, Finley E, et al. Standardizing falls reporting: using data from adverse event reporting to drive quality improvement. J Patient Saf. 2015;September 1, 2015;PMID:26332598.

2. Commonwealth of Pennsylvania Patient Safety Authority. Training manual and users’ guide. Using the Pennsylvania Patient Safety Reporting System (PA-PSRS). Version 6.5, June 2015. https://www.papsrs.state.pa.us/PSA/_pdf/PA-PSRS%20User%20Manual.pdf.

## Applied Research

Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case-Control Study of Hospitalized Patients. *Applied Nursing Research*, Vol. 16, No. 1 (February), 2003: pp 9-21 by Ann L. Hendrich, Patricia S. Bender and Allen Nyhuis.

[Review our applied research](https://uprightfallprevention.com/fall-prevention-research/)

## Across the Continuum of Care

- [Managed Care](https://uprightfallprevention.com/continuum-of-care/)
- [Acute Care](https://uprightfallprevention.com/continuum-of-care/)
- [Ambulatory Care](https://uprightfallprevention.com/continuum-of-care/)
- [Medical Home/Assisted Living](https://uprightfallprevention.com/continuum-of-care/)
- [Population Health](https://uprightfallprevention.com/continuum-of-care/)

## Fall Prevention Updates

Fall related news and research summaries published on this site between 2013 and 2015.

- November 2, 2015 [In-Hospital Neck of Femur Fractures Increased Mortality](https://uprightfallprevention.com/hospital-neck-femur-fractures-increased-mortality/)
- November 2, 2015 [Falls Screening in England and Wales](https://uprightfallprevention.com/falls-screening-england-wales/)
- November 2, 2015 [Expanding Adverse Event Reporting to Drive Quality Improvement](https://uprightfallprevention.com/expanding-adverse-event-reporting-drive-quality-improvement/)

[Read fall related news](https://uprightfallprevention.com/hendrich-ii-fall-risk-model/in-the-news/)

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## Contact

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