85 Implementation strategies of fall prevention interventions in hospitals: A systematic review 3 Our review has several limitations, one of them being the application of the risk of bias tool for the non-randomized studies. In hindsight, we would have assessed the risk of bias for all the non-randomized studies using the ROBINS-I tool [85] instead of the NOS [22]. The ROBINS-I tool offers a structured approach to assess risk of bias due to confounding. We believe that the answer options ‘probably yes’ and ‘probably no’, along with the ability of using free text to provide support for each answer, using direct quotes from the study text would increase the objectivity of risk of bias assessments for included non-randomized studies. Another limitation is inaccessibility of published data. We choose to only include published data, while an alternative approach could have involved reaching out to authors to request missing data. We emphasize the importance of publishing information regarding the intervention components (FPIs), execution of implementation efforts, and duration of all implementation phases. These details are essential for a thorough comprehension of study outcomes and align with currently available reporting guidelines. Standards for Reporting Implementation Studies (StaRI) is a useful reporting guideline that highlights essential aspects of implementation studies [86]. We strongly recommend that implementation researchers should be more engaged in publishing these kind of studies, to stop publishing studies that fail to report their implementation strategies in accordance with available reporting guidelines. Implementation researchers should be able to ensure reproducibility, generalizability and increase the use of implementation research logic models [87] to reduce published studies from which others are unable to learn [88]. Conclusion In this study, we investigated the strategies employed for implementing FPIs to reduce falls in hospitals. Most of the studies reported using at least one implementation strategy that would fit in the domain ‘train and educate stakeholders’. While most of the implemented FPIs seemed to effectively reduce in-hospital fall rates, we could not single out any specific implementation strategy or set of strategies as being most effective. The added value of using an implementation theory, model or framework was not clearly reported. The operationalization of the strategies lacked sufficient details, which hampers the reproducibility of the implementation efforts. This, in turn, hinders clinicians to select evidence-based improvement strategies for implementing FPIs and impedes researchers from exploring relationships between implementation strategies and implementation outcomes.
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