Falls prevention is a cornerstone of quality improvement in the care of older adults, yet the metrics through which it is operationalised warrant scrutiny. Current quality frameworks in acute and post-acute settings overwhelmingly treat falls as discrete sentinel events while treating functional decline as a background condition unworthy of equivalent measurement. This commentary identifies this asymmetry as a distinct governance problem, which we term event-based safety governance: the systematic privileging of countable adverse events over longitudinal harms in quality oversight. In this context, governance refers to the regulatory, reporting and performance measurement systems that shape organisational accountability and clinical priorities. Previous authors have described the clinical tension between promoting mobility and preventing falls. We advance that discussion by arguing that the problem is not merely clinical but structural: the measurement architecture itself generates defensive practice by making falls visible to institutional accountability while rendering immobility-driven decline invisible. We propose that functional trajectory monitoring, embedded alongside fall event reporting, would correct this imbalance by making the harms of inactivity organisationally legible. Until quality measurement in the care of older adults accounts for what patients lose through enforced stillness, often an unintended consequence of system-level incentives, as rigorously as it accounts for what happens when they fall, clinical judgement will remain subordinate to institutional risk avoidance. We propose three practical reforms: routine functional trajectory monitoring, integration of mobility outcomes into organisational quality dashboards and explicit recognition of mobilisation as a safety-aligned clinical activity.

Saddle pulmonary embolism (PE) complicated by right atrial thrombus in transit is an infrequent but highly lethal condition. Standard treatments such as systemic thrombolysis or surgical embolectomy carry significant risks, particularly in elderly or comorbid patients. We describe the case of a 76-year-old man with spina bifida, cauda equina syndrome, chronic immobility, and multiple comorbidities who presented in shock. Imaging revealed a large saddle PE with mobile right atrial thrombus and right ventricular strain. Given prohibitive surgical risk and contraindications to thrombolysis due to recent spinal infection and acute kidney injury, and high bleeding risk, he underwent percutaneous suction thrombectomy using the FlowTriever system. Large thrombus burden was successfully removed from both the right pulmonary artery and right atrium, with restoration of flow and hemodynamic stabilization. He was transitioned to long-term anticoagulation and discharged in stable condition. This case highlights the role of dual-site suction thrombectomy as a life-saving option when conventional therapies are contraindicated.

Mechanical ventilation is lifesaving yet harmful when paired with deep sedation and immobility. The ABCDEF, or intensive care unit liberation bundle (assessment and treatment of pain, spontaneous awakening and breathing trials, judicious choice of analgesia/sedation, delirium prevention/management, early mobility, and family engagement) mitigates these risks, improving survival, reducing delirium and coma, shortening time receiving ventilation, and promoting recovery. This article synthesizes evidence for the awake-and-walking intensive care unit, in which wakefulness and mobility are the default. We define the role of the advanced practice registered nurse in reliable implementation of this model: embedding bundle elements into workflows, aligning sedation and mobility targets, coordinating interprofessional teams, and driving culture change through measurement and feedback. A case example illustrates a patient's trajectory under high versus low adherence. We close with pragmatic strategies to overcome workflow fragmentation, staffing variability, and safety concerns, mapping barriers to solutions such as protocol standardization, nurse-respiratory therapist coleadership, daily goal alignment, and data transparency.