, the most common event leading to a fall was either the patient on the commode or transferring to the toilet. The simulation empha sized the need to place a bedside commode in the patient's room, stay with the patient while he or she was on the toilet, and perform hourly rounding. This was a key component pertaining to PSR data utilization application with an evidence based approach, innovation, and intervention. The TeamSTEPPS simulation feedback included critical