Preventing Falls in

Preventing Falls in

Hospitals
A Toolkit for Improving
Quality of Care
The information in this toolkit is intended to assist service providers
and hospitals in developing falls prevention protocols. This toolkit is
intended as a reference and not as a substitute for professional
judgment. The opinions expressed in this document are those of the
authors and do not necessarily reflect the views of AHRQ. No
statement in this toolkit should be construed as an official position of
AHRQ or the U.S. Department of Health and Human Services. In
addition, AHRQ or U.S. Department of Health and Human Services
endorsement of any derivative product may not be stated or implied.
Preventing Falls in Hospitals
A Toolkit for Improving Quality of Care
Prepared for:
Agency for Healthcare Research and Quality

540 Gaither Road
Rockville, MD 20850
www.ahrq.gov
Prepared by:
RAND Corporation
Boston University School of Public Health
ECRI Institute
Contract No. HHSA290201000017I TO #1
AHRQ Publication No. 13-0015-EF

January 2013
Authors
RAND Corporation
David A. Ganz, M.D., Ph.D., VA Greater Los Angeles Healthcare System, University of
California at Los Angeles, and RAND Corporation
Christina Huang, M.P.H., RAND Corporation
Debra Saliba, M.D., M.P.H., VA Greater Los Angeles Healthcare System, UCLA/JH Borun
Center for Gerontological Research, and RAND Corporation
Victoria Shier, M.P.A., RAND Corporation
Boston University School of Public Health
Dan Berlowitz, M.D., M.P.H., Bedford VA Hospital and Boston University School of Public
Health
Carol VanDeusen Lukas, Ed.D., VA Boston Healthcare System and Boston University School of
Public Health
ECRI Institute
Kathryn Pelczarski, B.S.

Karen Schoelles, M.D., S.M.
Linda C. Wallace, M.S.N., B.S.N.
Patricia Neumann, R.N., M.S.
This document is in the public domain and may be used and reprinted without special
permission. Citation of the source is appreciated.
Suggested citation:
Ganz DA, Huang C, Saliba D, et al. Preventing falls in hospitals: a toolkit for improving quality
of care. (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI
Institute under Contract No. HHSA290201000017I TO #1.) Rockville, MD: Agency for
Healthcare Research and Quality; January 2013. AHRQ Publication No. 13-0015-EF.
ii
Contents
Roadmap ..........................................................................................................................................v
Acknowledgments.......................................................................................................................... ix
Overview ..........................................................................................................................................1
The Problem of Falls ..................................................................................................................1
The Challenges of Fall Prevention .............................................................................................1
Toolkit Designed for Multiple Audiences .................................................................................2
Implementation Guide Organized To Direct Hospitals Through the Change Process ..............3
Sections of the Guide .................................................................................................................3
Adaptation of the Guide to Your Organization..........................................................................3
Improvement as Puzzle Pieces ...................................................................................................4
Icons .................................................................................................................................................5
1. Are you ready for this change? ....................................................................................................6
1.1. Do organizational members understand why change is needed?........................................6
1.2. Is there urgency to change?.................................................................................................8
1.3. Does senior administrative leadership support this program? ............................................9
1.4. Who will take ownership of this effort? ...........................................................................11
1.5. What kinds of resources are needed? ................................................................................12
1.6. What if you are not ready for full-scale change? ..............................................................12
1.7. Checklist for assessing readiness for change ....................................................................13
2. How will you manage change? ..................................................................................................14
2.1. How can you set up the Implementation Team for success? ............................................15
2.2. What needs to change and how do you need to redesign it? ............................................19
2.3. How should goals and plans for change be developed? ...................................................25
2.4. Checklist for managing change .........................................................................................26
3. Which fall prevention practices do you want to use? ................................................................27
3.1. Which fall prevention practices should you use? .............................................................28
3.2. What are universal fall precautions and how should they be implemented? ....................30
3.3. What is a standardized assessment of risk factors for falls, and how should this
assessment be conducted? ............................................................................................34
3.4. How should identified risk factors be used for fall prevention care planning? ................38
3.5. How should you assess and manage patients after a fall? ................................................46
3.6. How can your hospital incorporate these practices into a fall prevention program? ........49
3.7. What additional resources are available to identify best practices for fall prevention? ...51
3.8. Checklist for best practices ...............................................................................................51
4. How do you implement the fall prevention program in your organization? .............................52
4.1. What roles and responsibilities will staff have in preventing falls? .................................53
4.2. What fall prevention practices go beyond the unit?..........................................................59
4.3. How do you put the new practices into operation? ...........................................................60
4.4. Checklist for implementing best practices ........................................................................67
5. How do you measure fall rates and fall prevention practices? ..................................................68
5.1. How do you measure fall and fall-related injury rates? ....................................................69
5.2. How do you measure fall prevention practices? ...............................................................77
5.3. Checklist for measuring progress......................................................................................80
iii
6. How do you sustain an effective fall prevention program? .......................................................81
6.1. Who will be responsible for sustaining active fall prevention efforts on
an ongoing basis? .........................................................................................................82
6.2. How will you continue to monitor fall rates and fall prevention care processes? ............82
6.3. What types of ongoing organizational support do you need to keep the new
practices in place? ........................................................................................................83
6.4. How can you reinforce the desired results? ......................................................................84
6.5. Summary ...........................................................................................................................87
7. Tools and Resources ..................................................................................................................89
Appendix: Bibliography of Studies Implementing Fall Prevention Practices .............................185
iv
Roadmap
Who Should Use The
Section Action Steps Tool That Supports Action Tool
Overview Enlist support of senior leaders Tool A, Introduction and Overview for Senior manager
Stakeholders
Section 1 Are you ready for this change?
1.1 Assess the culture of safety in your Tool 1A, Hospital Survey on Patient Safety Culture All interdisciplinary
hospital team members
1.2 Evaluate current organizational Tool 1B, Stakeholder Analysis Implementation Team
attention to falls leader
1.3 Assess and develop leadership Tool 1C, Leadership Support Assessment Implementation Team
support for the fall prevention leader
program Tool 1D, Business Case Form
1.5 Identify resources that are available Tool 1E, Resource Needs Assessment Implementation Team
and resources that are needed leader
1.7 Assess your progress on completing Tool 1F, Organizational Readiness Checklist Implementation Team
readiness for change activities leader
Section 2 How will you manage change?
2.1 Identify your Implementation Team Tool 2A, Interdisciplinary Team Implementation Team
leader
2.2 Assess the current status of fall Tool 2B, Quality Improvement Process Implementation Team
prevention activities in your leader, individuals
hospital Tool 2C, Current Process Analysis designated by the
v
Tool 2D, Assessing Current Fall Prevention Policies Implementation Team
and Practices leader
Determine staff knowledge about Tool 2E, Fall Knowledge Test Staff nurses and
fall prevention nursing assistants
2.3 Set goals for improvement based on Tool 2F, Action Plan Implementation Team
outcomes and processes leader with quality
improvement/safety/ris
k manager
Who should use the

Section Action Steps Tool That Supports Action tool
2.4 Assess your progress on completing Tool 2G, Managing Change Checklist Implementation Team
the managing change activities leader
Section 3 Which fall prevention practices do you want to use?
3.1 Identify how fall prevention care Tool 3A, Master Clinical Pathway for Inpatient Falls Quality
processes connect to one another improvement/safety/ris
k manager, staff
nurses, nursing
assistants
3.2 Implement universal fall Tool 3B, Scheduled Rounding Protocol Unit manager, staff
precautions nurses, nursing
Tool 3C, Tool Covering Environmental Safety at the assistants, facility
Bedside engineer, hospital
employee who enters
Tool 3D, Hazard Report Form patient rooms
Tool 3E, Clinical Pathway for Safe Patient Handling
vi
3.3 Identify important risk factors for Tool 3F, Orthostatic Vital Sign Measurement Staff nurses,
falls in your patients pharmacist, nursing
Tool 3G, STRATIFY Scale for Identifying Fall Risk assistants
Factors
Tool 3H, Morse Fall Scale for Identifying Fall Risk

Factors
Tool 3I, Medication Fall Risk Scale and Evaluation

Tools
3.4 Use identified fall risk factors to Tool 3J, Delirium Evaluation Bundle: Digit Span, Educators, staff nurses,
implement fall prevention care Short Portable Mental Status Questionnaire, and physicians, nurse
planning Confusion Assessment Method practitioners, physician
assistants, nursing
Tool 3K, Algorithm for Mobilizing Patients assistants
Tool 3L, Patient and Family Education
Tool 3M, Sample Care Plan
3.5 Assess and manage patients after a Tool 3N, Postfall Assessment, Clinical Review Staff nurses and
fall physicians
Tool 3O, Postfall Assessment for Root Cause
Analysis
Who should use the

Section Action Steps Tool That Supports Action tool
3.8 Assess your progress on completing Tool 3P, Best Practices Checklist Implementation Team
the best practices activities Leader
Section 4 How do you implement the fall prevention program in your organization?
vii
4.1 Assign staff roles and Tool 4A, Assigning Responsibilities for Using Best Implementation Team
responsibilities for tasks identified Practices Leader, Unit manager
in set of best practices
Tool 4B, Staff Roles
4.3 Assess current staff education Tool 4C, Assessing Staff Education and Training Implementation Team
practices and facilitate integration Leader
of new knowledge on fall
prevention into existing or new
practices
4.4 Assess your progress on Tool 4D, Implementing Best Practices Checklist Implementation Team
implementing best practices Leader
activities
Section 5 How do you measure fall rates and fall prevention practices?
5.1 Collect the right data to learn about Tool 5A, Information To Include in Incident Reports Quality
falls, fall-related injuries, and their improvement/risk
causes manager, information
systems staff
5.2 Measure fall prevention practices Tool 5B, Assessing Fall Prevention Care Processes Unit manager and unit
champions
5.3 Assess your progress on measuring Tool 5C, Measuring Progress Checklist Implementation Team
progress activities Leader
Section 6 How do you sustain an effective fall prevention program?
6.3 Identify factors need to sustain your Tool 6A, Sustainability Tool Implementation Team
fall prevention efforts Leader
viii
Acknowledgments
William Spector, Ph.D., Senior Social Scientist at AHRQ, acted as project officer for this task
order to develop a toolkit. Rhona Limcangco, Ph.D., Health Analyst at AHRQ, provided
additional support in carrying out the project.
The development of this toolkit was facilitated by the assistance of quality improvement teams at
six medical centers:
Joyce Dolin, Jena Reilly, and Kendra Belkin at Charlton Memorial Hospital (Fall River,
MA);
Jerry Lockett, Clover Irving-Wiggins, and Mariely Maldonado at Florida Hospital East
Orlando (Orlando, FL);
Martha Syms, Kelley Williams, and Kaye McMullin at St. Marys Regional Medical
Center (Enid, OK);
Myka Whitman, Emmet Polster, and Amanda Mahaffee at Northwest Texas Hospital
(Amarillo, TX);
Linda Gehring, Marie Cicerone, and Sarah Knuckles at Temple University Hospital
(Philadelphia, PA); and
Pat Benson, Michele Davis, and Terry Bryan at Augusta Health (Fishersville, VA).
We thank them for their valuable contributions.
We also thank the authors of the evidence review that provided background information for this
toolkit: Susanne Hempel, Ph.D.; Sydne Newberry, Ph.D.; Zhen Wang, Ph.D.; Paul G. Shekelle,
M.D., Ph.D.; Roberta Shanman, M.S.; Breanne Johnsen; and Tanja Perry.
We thank Walid Gellad, M.D., our internal peer reviewer as part of RANDs quality assurance
process, for his constructive and detailed comments.
We thank our technical expert panel, Katherine Berg, PT, Ph.D.; Sharon K. Inouye, M.D.,
M.P.H.; Suzan N. Kucukarslan, R.Ph., Ph.D.; Dale M. Needham, M.D., Ph.D.; Julia B. Neily,
R.N., M.S., M.P.H.; Patricia Quigley, A.R.N.P., Ph.D.; Laurence Rubenstein, M.D., M.P.H.;
Blair L. Sadler, J.D.; Stephanie Studenski, M.D., M.P.H.; and Catherine (Cait) Walsh, R.N.,
M.S.N, for their advice on this document.
We also thank Andrew Bernard, M.D., and colleagues at University of Kentucky Medical Center
and UK Healthcare; Cynthia J. Brown, M.D., M.S.P.H; Patricia C. Dykes, D.N.Sc., R.N.,
F.A.A.N., F.A.C.M.I.; Anne M. Drolet, M.S., A.N.P.-B.C., C.C.R.N.; Victoria Fraser, M.D.;
Terry Haines, Ph.D.; Frances Healey, R.N., Ph.D.; Serena Koh, R.N., Ph.D.; David Oliver, M.B.,
B.Chir., D.G.M., D.M.E., M.H.M, M.D., M.Sc., M.A., F.R.C.P; and Ronald I. Shorr, M.D.,
M.S., for sharing their advice and materials.
ix
Overview
The Problem of Falls
Each year, somewhere between 700,000 and 1,000,000 people in the United States fall in the
hospital.i A patient fall is defined as an unplanned descent to the floor with or without injury to
the patient.ii A fall may result in fractures, lacerations, or internal bleeding, leading to increased
health care utilization. Research shows that close to one-third of falls can be prevented.iii As of
2008, the Centers for Medicare & Medicaid Services (CMS) does not reimburse hospitals for
certain types of traumatic injuries that occur while a patient is in the hospitaliv; many of these
injuries could occur after a fall.
Staff in acute care hospitals have a complex and potentially conflicting set of goals when treating
patients. Hospital personnel need to treat the problem that prompted the patients admission,
keep the patient safe, and help the patient to maintain or recover physical and mental function.
Thus, fall prevention must be balanced against other priorities. Fall prevention involves
managing a patients underlying fall risk factors (e.g., problems with walking and transfers,
medication side effects, confusion, frequent toileting needs) and optimizing the hospitals
physical design and environment. A number of practices have been shown to reduce the
occurrence of falls, but these practices are not used systematically in all hospitals.
The Challenges of Fall Prevention

Fall prevention requires an interdisciplinary approach to care. Some parts of fall prevention care
are highly routinized; other aspects must be tailored to each patients specific risk profile. No
clinician working alone, regardless of how talented, can prevent all falls. Rather, fall prevention
requires the active engagement of many individuals, including the multiple disciplines and teams
involved in caring for the patient. To accomplish this coordination, high-quality prevention
requires an organizational culture and operational practices that promote teamwork and
communication, as well as individual expertise.
Fall prevention activities also need to be balanced with other considerations, such as minimizing
restraints and maintaining patients mobility, to provide the best possible care to the patient.
Therefore, improvement in fall prevention requires a system focus to make needed changes.
i
Estimate from Currie LM. Fall and injury prevention. In: Patient safety and quality. an evidence-based handbook
for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043.
Available at: www.ahrq.gov/qual/nurseshdbk/docs/CurrieL_FIP.pdf.
ii
This definition comes from the National Database of Nursing Quality Indicators. For the full definition, see
resource box in section 5.1.2.
iii
See Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care
facilities and hospitals. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD005465.
iv
As of October 2012, CMS list of codes for falls and trauma includes fractures, dislocations, intracranial injuries,
crushing injuries, burns, and other injuries (such as hypothermia). The specific Comorbidity and
Complication/Major Comorbidity and Complication codes are 800-829; 830-839; 850-854; 925-929; 940-949; and
991-994. CMS may update these codes periodically, so check the CMS Web site at www.cms.gov for guidance.
Overview 1
Toolkit Designed for Multiple Audiences
This toolkit focuses on overcoming the challenges associated with developing, implementing,
and sustaining a fall prevention program. Therefore, you will find that a good deal of the toolkit
is focused on successfully negotiating a change process at your hospital. This is what we feel
makes the toolkit unique. The toolkit was developed under a contract with the Agency for
Healthcare Research and Quality through the ACTION II program (Accelerating Change and
Transformation in Organizations and Networks). It was created by a core team with expertise in
fall prevention and organizational change. The team included staff from the RAND Corporation,
ECRI Institute, and Boston University.
This toolkit focuses specifically on reducing falls during a patients hospital stay. For more
information on how to prevent falls outside the hospital, see the American Geriatrics Society
guidelines at www.americangeriatrics.org/health_care_professionals/clinical_practice/
clinical_guidelines_recommendations/2010/ ) and the Centers for Disease Control and
Prevention STEADI Toolkit at www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html.
Efforts to prevent falls outside the hospital will help reduce the number of patients admitted to
the hospital for fall-related injuries.
The toolkits content draws on a systematic review of the literature.v We also drew heavily on
expert opinion regarding best practices in fall prevention.vi We used the literature wherever
possible to support our recommendations. Throughout the toolkit you will find citations to
relevant literature where it exists.
In many cases, the literature was unclear or silent about key aspects of care, or implementation
strategies were not reported in adequate detail. Therefore, we sought guidance from an expert
panel and additional experts in the field. We merged this input with our own experience both as
clinicians working in acute care hospitals and as quality improvement specialists who work with
hospitals to improve their fall prevention programs. In addition, six hospitals volunteered to test
the toolkit as part of this project. Their feedback influenced this final version and many of the
resource boxes throughout the toolkit reflect their experiences.
The toolkit is designed for multiple uses. The core document is an implementation guide
organized under six major questions intended to be used primarily by the Implementation Team
charged with leading the effort to put the new prevention strategies into practice.vii The full guide
v
See Hempel S, Newberry S, Wang Z, et al. Review of the evidence on falls prevention in hospitals. RAND
Working Paper. (Prepared for the Agency for Healthcare Research and Quality, Contract No.
HHSA2902010000171, PRISM no. HHSA2903200IT, Task Order #1). Publication No. WR-907-AHRQ. Santa
Monica, CA: RAND; 2012. Available at: www.rand.org/pubs/working_papers/WR907.html. Also see Appendix,
Bibliography of Studies Implementing Fall Prevention Practices, for details.
vi
In the context of this toolkit, best practices refers to both (1) a standard way of developing, implementing, and
sustaining a hospital fall prevention program; and (2) those clinical care processes that, based on literature and
expert opinion, represent the best way of preventing falls in the hospital.
vii
We conceive of the Implementation Team as a standing committee charged with overseeing the hospitals fall
prevention program. Joint Commission standards require ongoing efforts to assess risk for falls and to intervene to
reduce fall risk; staff education regarding fall prevention; and an evaluation of the effectiveness of the hospitals fall
prevention strategies, including fall risk assessment, interventions, and education. Therefore, many hospitals already
have in place a fall committee that could become the Implementation Team.
Overview 2
also includes links to tools and resources found in the Tools and Resources section of the
toolkit, on the Web, or in the literature. The tools and resources are designed to be used by
different audiences and for different purposes, as indicated in the guide.
Because it is important to have your facilitys leadership engaged, the toolkit includes a letter to
introduce the program to other key players, such as hospital senior management and unit nurse
managers. This letter may be found at the beginning of section 7 (Tool A, Introduction and
Overview for Stakeholders). The toolkit also contains an Action Plan (Tool 2F), which
provides a quick overview of the steps needed to implement and sustain a fall prevention
program. In addition, it contains an Interdisciplinary Team tool (Tool 2A), which has a matrix
of all the tools in this toolkit organized by the types of hospital personnel who would most likely
use them (e.g., tools for nursing staff, rehab personnel, pharmacists).
Implementation Guide Organized To Direct Hospitals Through the Change

Process
To implement a successful initiative to improve fall prevention on a sustained basis, your
organization will need to address six questions:
o Are you ready for this change?

o How will you manage change?
o Which fall prevention practices do you want to use?
o How do you implement best practices in your organization?
o How do you measure fall rates and fall prevention practices?
o How do you sustain an effective fall prevention program?
Sections of the Guide

The six questions make up the major sections of the implementation guide. Each major question
is in turn organized by a series of more detailed questions to guide the Implementation Team
through the improvement process, as summarized in the table of contents. Each section begins
with a brief explanation of why the question is relevant and important to the change process or to
fall prevention. Each section concludes with action steps and specific resources to support the
actions needed to address the questions. Additional resources that may be helpful to
implementers may be found in the appendix Bibliography of Studies Implementing Fall
Prevention Practices.
Each section also suggests specific tools and resources to assist you. In addition, printer-friendly
versions of all these referenced tools and resources are compiled in section 7. Some resources are
intended for the Implementation Team to use during the planning and system change process.
Others are designed as educational materials or clinical tools to be used by unit staff as they
implement the new strategies and use them on an ongoing basis. Sections also include references
or links to more detailed resources for those who want to explore an issue in more detail.
Adaptation of the Guide to Your Organization

While the implementation guide is designed to cover the full improvement process from deciding
to make changes to monitoring sustainability, some sections may be more relevant than others if
your organization has already begun the improvement process. Sections 1 and 2 are intended to
Overview 3
guide you through an assessment of your readiness to change and help you plan your processes
to change.
Hospitals may have their own approaches in tailoring the toolkit to their needs. The guide can be
used as a reference document with sections consulted selectively as needed. To help you find the
pieces you need, the questions that guide the full process are listed in the table of contents and
the location of subjects can be found in the roadmap.
Because the changes needed are usually complex, most organizations take at least a year to
develop, incorporate, and consolidate the new fall prevention practices. Some take longer as
early accomplishments uncover the need and opportunity for further improvements. It will be
important to balance the need to proceed thoughtfully with the need to move quickly enough to
show progress and maintain momentum.
Improvement as Puzzle Pieces

The path through the guide is not a single sequence of steps. Instead, the sections can be better
viewed as interlocking pieces of a puzzle, for two reasons. First, the components of improvement
are not linear and independent; one piece may depend on another and work will need to move
back and forth between them. Second, each hospital may choose to start with a different section
of the guide, depending on its local needs.
We present this view of the guide as a puzzle with the image below. To orient readers using the
guide, we repeat this image at the beginning of each section with the content of the section
highlighted. In addition, throughout the guide, we explicitly cross-reference subsections where
assessments, decisions, or tools in one area will contribute to deliberations or actions in another.
Overview 4
Icons
Throughout this toolkit, icons signal different types of resources to assist you:
Action and Resource Symbols
Denotes action steps
Denotes a tool for this action in Tools and Resources
Denotes a linked tool or other resource for this action
Denotes practice insights
Includes added commentary or examples drawn from

experiences in a variety of organizations, including the
hospitals that tested this toolkit
Denotes additional background material for those

interested in pursuing this area in more detail
Overview 5
1. Are you ready for this change?
Falls represent a considerable problem in hospitals. Efforts
to improve fall prevention require a system approach that
achieves organizational change through multiple,
simultaneous modifications to workflow, communication,
and decisionmaking. This type of organizational change can
be difficult to achieve. Failure to assess your organizations
readiness for change can lead to unanticipated difficulties in
implementation, or even the complete failure of the effort.
Each question below will help you and your organization

explore readiness and identify any needed actions to
improve it:
Do organizational members understand why change

is needed?
Is there urgency to change?
Does senior leadership support this initiative?
Who will take ownership of this effort?
What resources are needed?
What if you are not ready for full-scale change?
Organizational Readiness for Change: Locally Relevant Considerations
Even hospitals whose leaders are ready to support change may face barriers to
further progress. For example, senior leadership may believe that effective fall
prevention is essential and may demonstrate that fall prevention is a high
priority. However:
Some hospitals may experience significant turnover in senior leadership

and nursing leadership.
Competing patient safety and quality priorities may affect resource
availability.
This section of guide addresses these types of issues.
1.1. Do organizational members understand why change is needed?

Knowing how care should be delivered is only one step in the process of improving fall
prevention. Readiness requires both the capability to make changes and the motivation to
change. That motivation may be helped along by external factors, such as Federal or State
mandates. But the motivation is most likely to be strong and enduring if based on a clear
understanding of the concerns behind the planned change at all levels of the organization.
One of way of finding out whether people within your hospital understand why change is needed
is to perform a survey. Consider administering a general survey, such as the AHRQ Hospital
Section 1: Assess Readiness 6

Survey on Patient Safety Culture (Tool 1A, Hospital Survey on Patient Safety Culture) to
assess the culture of safety in your hospital.
There are many potential reasons to implement a fall prevention program. While we offer
general reasons and statistics in the box below, local reasons or cases may be more tangible and
compelling. For example:
Has your facility experienced a significant increase in fall rates?

Have there been any adverse events that were fall related?
Has your facility been the target of a legal action related to a fall?
Do staff members have personal experience of a family member affected by a fall?
Did you know?
Falls are common: Falls are the most frequently reported incident in adult inpatient units.
The rate of falls ranges from 1.7 to 25 falls per 1,000 patient days (see sections 5.1.3 to
5.1.5 for an explanation of rates), depending on the unit, with geriatric psychiatry patients
having the highest risk.a
There is a business case for fall prevention: Falls are associated with increased length of
stay, higher rates of discharge to nursing homes, and greater health care utilization.b One
study found that operational costs for fallers with serious injury were $13,316 higher than
nonfallers.c As of 2008, Medicare no longer reimburses hospitals for increased costs due
to injury from an inpatient fall.d
Falls harm our patients: Thirty to 51 percent of falls in hospitals result in some injury,b
varying from bruises to severe wounds or bone fractures.
a
1. Currie LM. Fall and injury prevention. Patient safety and quality. an evidence-based handbook for nurses.
Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-0043. Available
at: www.ahrq.gov/qual/nurseshdbk/docs/CurrieL_FIP.pdf.
b
2. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med
2010;26(4):645-92.
c
3. Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern
hospitals. Jt Comm J Qual Patient Saf 2011;37(2):81-7.
d
4. See www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalAcqCond/Downloads/HACFactsheet.pdf and www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/HospitalAcqCond/EducationalResources.html for details.
Lasting improvement is more likely to occur if the various people influencing fall prevention
have a shared set of knowledge and motivations. Those initiating interventions to prevent falls
may clearly understand the needed changes. However, knowledge and motivation to change may
vary greatly across the organization. Others in your hospital may have different reasons for
wanting change, so it is important to define the issues and reasons for change in advance. This
process will help make the case for why a fall prevention initiative is needed now.
Updating knowledge and changing attitudes require both sharing new information and dealing
with existing knowledge and attitudes that may undermine change efforts if left unaddressed. Be
sure to assess the knowledge and attitudes of all types of staff members involved in clinical care,
since awareness of the importance of fall prevention is an interdisciplinary responsibility.

Consider administering a survey to assess the culture of safety in your
hospital. The AHRQ Hospital Survey on Patient Safety Culture
examines patient safety culture from a hospital staff perspective. This
survey can be found in Tools and Resources (Tool 1A, Hospital Survey
on Patient Safety Culture). The results of the survey can be used to
identify areas for improvement in your hospitals culture.
Develop consensus on reasons a fall prevention program needs to go forward.
Developing consensus involves multiple steps:
Identify the reasons for having a fall prevention program in your

organization. If the reasons are general and not specific to your hospital,
try to find cases or examples that help bring the issue home to your
facility.
Determine your facility leaderships interests and needs in this area, and
assess how much effort will be needed to obtain and sustain their
support.
Talk with other people (from various levels, roles, and clinical areas)
who support implementing a fall prevention program. This group may
include as many as 10 or 20 people who have a stake in this issue.
Based on this input, begin to clarify the shared reasons justifying
change.
Assess the extent to which organizational members beyond potential
supporters understand why a comprehensive fall prevention program is
important. This step can be completed in a variety of ways, such as
small group meetings, surveys, or a review of quality concerns raised by
organizational members.
Consider identifying one unit where the problem with falls is worst or
where staff are most enthusiastic about fall reduction. These staff are
most likely to understand why change is needed, so find out what they
think.
1.2. Is there urgency to change?

Beyond understanding why change is needed to improve fall prevention, do organizational
members find the need compelling? If a sense of urgency does not yet exist among key
organizational leaders and members, your job as change agents is to increase or create it. At this
early stage, the focus is on urgency at the organizational level. Awareness and knowledge for
change at the unit level will be discussed in section 2.2.
Consider the aspects of the problem that will be most compelling to your stakeholders. Are there
different aspects that are relevant and persuasive for different audiences within the hospital? For
example, for some audiences, a business case for reducing falls may be more compelling; for
others, the clinical benefits may be more relevant.
In considering your arguments, you will need to evaluate current organizational attention to falls.
For example, who has lead responsibility for fall prevention? Are fall rates regularly documented

and reported? If so, who receives and acts on the reports? Answers to these questions will
influence the way you make your case for improving fall prevention.
If your facility staff do not understand why improving fall prevention is important, your task of
increasing urgency will be more difficult. Mounting an effective improvement effort will likely
require greater support from leadership, as discussed in section 1.3, and more resources, as
described in section 1.5.
Based on your current understanding of the situation, begin to explore topics or themes that can
be used to increase awareness and urgency. Consider framing your efforts in line with broader
initiatives, such as the Institute for Healthcare Improvement Triple Aim
(www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx).
Reach out beyond those who already support efforts to strengthen fall
prevention. Begin talking with additional colleagues about fall
prevention and why it is important at your health care organization.
Listen to their responses to gather important information about barriers
of awareness and understanding that you may need to address later
with education.
Conduct a stakeholder analysis to identify key people and departments
that may have a stake in the success of this program.
A template for stakeholder analysis can be found in Tools and Resources (Tool
1B, Stakeholder Analysis).
Consider using the introductory slide presentation developed by ECRI

Institute. [PowerPoint file, 92 KB] Note: ECRI Institute should be cited as the
source.
1.3. Does senior administrative leadership support this program?

You will need to ensure that your organizations leadership team (i.e., top-level administration,
medical staff leadership, and board of trustees) shares the urgency to change fall prevention
practices and is willing and able to provide complete and ongoing support for this effort. Lessons
learned from key fall prevention initiatives show that support is needed from both the top-level
administration as well as those at the bedside.
To make your case most effectively to leadership, ask yourself how support for a fall prevention
program fits with other institutional values and commitments. While you may not know at the
outset all the kinds of support that will be needed, you know that changes are going to require
new or reallocated resources, most likely both human and material. The changes will also require
focus and accountability for results, which will also need senior leadership oversight.

If senior leaders do not already strongly support the effort to strengthen fall prevention, you will
need to build the case for change. For some stakeholders, such as your chief financial officer, the
most compelling case may be a business case. You may discuss how much falls cost hospitals
each year in terms of longer lengths of stay, additional staff time, and reduced reimbursement
because Medicare no longer pays for preventable complications from falls. For other
stakeholders, such as clinical chiefs and nurse executives, it may be a clinical case discussing
how falls increase pain, functional impairment, morbidity, and mortality.
Many hospitals have a strong emphasis on quality improvement, with an improvement

infrastructure in place. Consider contacting quality improvement leaders in your organization for
guidance and possible assistance in enlisting leadership support. Also, you may want to enlist
quality improvement advisors to participate on your Implementation Team as described in
section 2.1.1.
To assess leadership support and other questions raised here, consider using a facility-level
assessment similar to Tool 1C, Leadership Support Assessment.
Hospital Leadership Team
A typical hospital includes these three leadership groups:
Top-level administration (e.g., chief executive officer, chief financial

officer, chief operating officer, chief medical officer, chief nursing
officer, chief quality officer, vice president of facilities and other vice
president-level staff).
Board of trustees.
Medical staff.
Hospitals vary with how they involve these groups in decisionmaking.

Depending on your goals for change, you should approach some or all of these
leadership groups to ensure buy-in.
The influence of top management, board, and physician leadership on hospital

quality improvement efforts is detailed in: Weiner BJ, Shortell SM, Alexander
J. Promoting clinical involvement in hospital quality improvement efforts: the
effects of top management, board, and physician leadership. Health Serv Res
1997;32(4):491-510. Available at:
www.ncbi.nlm.nih.gov/pmc/articles/PMC1070207/pdf/hsresearch00036-
0116.pdf.
The tool for assessing leadership support be found in Tools and Resources
(Tool 1C, Leadership Support Assessment).

Assess the level of leadership support for this change effort. Look
carefully at the yes and no answers in the leadership support
assessment. If no senior managers have been designated to oversee
patient safety, or no funds are earmarked for patient safety, patient
safety education, or champions for fall prevention, launching a fall
prevention program is likely to be extremely difficult, if not
impossible. Ideally, leaders will share the urgency to improve and will
help drive that urgency through the organization. However, if their
support is not adequate, take steps to inform leaders of the importance
and potential benefits associated with fall prevention.
Answer the following questions: Who are the key leaders? What will
get them on board, if they are not already on board? What will keep
them on board? Which senior leader can be the sponsor, link, or
champion for this effort?
Use what you learned about reasons for change identified by the
management and staff in your assessments.
A template for developing a business case for fall prevention can be found in
Tools and Resources (Tool 1D, Business Case Form).
For more information on making the business case for fall prevention, see
Forte J. How to build a successful business case for a falls-reduction program.
Best practices for falls reduction: a practical guide. Am Nurse Today
2011;6(2). Special Supplement. Available at:
www.americannursetoday.com/article.aspx?id=7634&fid=7364.
1.4. Who will take ownership of this effort?

Beyond the support of organizational leaders, improvement and change projects need strong
advocates, members of the organization who are committed to the projects goals and who can
influence others to get involved. Successful change projects must have broader support than just
one or two champions. Individuals who can take ownership of the effort can come from various
disciplines and may include physicians, nurse managers, physical or occupational therapists,
pharmacists, or staff members with a particular interest and expertise in fall prevention. Some or
all of these staff should make up the interdisciplinary Implementation Team that will guide the
improvement effort, as described in section 2.
Assess your organization to identify who the potential advocates of fall

prevention are likely to be. Some may be obvious, but others may not
be immediately evident.
Who cares about this issue? Why might it be important to them?
Organizationally, what would be the logical home base for this effort?
Would any individuals in that part of the organization be willing to take
ownership?

In identifying potential owners or champions for the effort, consider visiting
the AHRQ TeamSTEPPS Web site, which offers tips and suggestions for
enhancing organizational readiness: http://teamstepps.ahrq.gov/abouttips.htm.
1.5. What resources are needed?

In addition to the Implementation Team, improvement projects require resources of various
kinds, depending on the size and scope of the program. Launching an effort without first
ensuring adequate resources can derail your program at almost every step. Needed resources are
likely to include staff time for team meetings and initiatives, leadership time to monitor and
support team efforts, training and education time, and more tangible resources such as new care
products and communication materials. Cultivating local expertise in fall prevention is
particularly key in hospitals that do not have a content expert readily available.
Consider creating a checklist to identify resource needs, such as funds, staff education programs,
and information technology support. At the beginning of the program, the list of resources
needed is likely to be broad and will require refinement as the improvement efforts progress. In
developing the list, consider the resources already in place, such as a data system for reporting
fall rates and staff education programs. A detailed approach to determining current prevention
practices is described in section 2.2.2. At this early stage of determining whether change is
needed, the assessment of resources can be at a more general level.
This tool can be found in the Tools and Resources section (Tool 1E, Resource
Needs Assessment).
Take the time to develop a list of resources that are likely to be needed
as part of a fall prevention program.
Ask for what you will need to accomplish some significant changes.
1.6. What if you are not ready for full-scale change?

You should not move ahead with full-scale organizational change until you are confident of
organizational readiness. You can use the checklist in section 1.7 below to assess each of the
areas of organizational readiness for change that has been discussed in this section. To the extent
that readiness is not yet evident, or is only partial, it is critical to address those areas. At a
minimum, the facility must have one senior leader who understands the importance of this effort
and is committed to supporting the effort both in terms of resources and necessary changes to
work processes. In addition, evidence of a broader commitment to patient safety is an essential
component. If any of these elements are missing, you will need to first build support and
readiness before launching a full-scale change effort.

Some ways to build support and readiness may include:
a. Trying the changes in a single receptive unit to demonstrate success to the rest of the
organization and build the case for change;
b. Holding one-on-one meetings with key formal and informal leaders to present
information about the need for change and persuade them that the improvement efforts
will pay off;
c. Collecting and sharing data on fall rates in your facility to establish program relevance;
d. Identifying and recruiting program allies who can help spread the word; and
e. Conducting a general staff awareness campaign.
1.7. Checklist for assessing readiness for change

The Organizational Readiness Checklist and other end-of-chapter checklists are designed to
provide toolkit users with ways to check their progress through the assessment and
implementation steps discussed in the toolkit. They may be useful in ensuring that toolkit users
have not skipped essential steps (e.g., ensuring leadership support) in pursuing their fall
prevention efforts.
The checklist for assessing readiness for change can be found in Tools and
Resources (Tool 1F, Organizational Readiness Checklist).

2. How will you manage change?
Being ready for change is a necessary, but not sufficient,
prerequisite to changing your organizations approach to
fall prevention. Even when a health care organization is
armed with the best evidence-based information, willing
staff members, and good intentions, the implementation of
new clinical and operational practices still requires
additional careful organizational planning. Once you have
established organizational readiness, the next practice
change step is completing a thoughtful assessment of your
organizations current practices and knowledge about fall
prevention.
Your timeline should balance the need to act systematically

and thoughtfully with the need to move quickly enough to
maintain momentum by demonstrating progress. This
section is designed to help you manage change at the
organizational level. We will discuss managing change at
the unit level in section 4 and sustaining change in section 6.
In section 1.4, you identified members of the organization

who would be willing to take ownership of the improvement effort. As mentioned, we
recommend that some or all of those members serve on an Implementation Team to oversee the
improvement effort and manage the changes required. To maximize the possibility of successful
implementation of the fall prevention initiative, you need to consider the following questions:
How can you set up the Implementation Team for success?

o Who should serve on the Implementation Team?
o How can you help the Implementation Team get started on its work?
o How does the Implementation Team work with other teams involved in fall
prevention?
What needs to change and how do you need to redesign it?

o How do you start the work of redesign?
o What is the current state of fall prevention practice?
o What is the current state of staff knowledge about fall prevention?
How should goals and plans for change be developed?

o What goals should you set?
o How do you develop your plan for change?
How do you bring staff into the process?

o How do you get staff engaged and excited about fall prevention?
o How can you help staff learn new practices?
Section 2: Manage Change 14

Managing Change: Locally Relevant Considerations
In trying to manage change at the organizational level, your hospital may

experience some of these challenges:
The need for an effective fall prevention program, an interdisciplinary

approach, and shared ownership and accountability not penetrating
through all levels of staff.
Issues with staffing and culture: high turnover rates, inertia, and too
many initiatives competing for staff attention.
Difficulty establishing interdisciplinary teams:
o Many hospitals have nurse-driven fall prevention committees and

are transitioning to interdisciplinary teams.
o Fall prevention roles need to be better defined across disciplines,
and some disciplines have not bought into the need to play a
proactive role in fall prevention.
These types of challenges are addressed in this section.
2.1. How can you set up the Implementation Team for success?
The center of successful improvement efforts in fall prevention tends to be an interdisciplinary
Implementation Team that has:
A strong link to hospital leadership,

Members with the necessary expertise,
A clearly defined aim (e.g., develop a program to reduce fall incidence by 15% in our
hospital in the next year), and
Access to the resources needed to accomplish the aim.
If you already have a hospital fall prevention committee, the committee can become your
Implementation Team. This team should include stakeholders who represent the broad range of
organizational members with potential roles in fall prevention.
Trying to find one person who can do all these things, instead of a team, is both difficult and
risky. Fall prevention is a process that cuts across many different areas of hospital operations and
thus requires input from all those areas. In addition, forming a team ensures that efforts will
continue even if one or more members move to other activities.
The Implementation Team generally assumes overall responsibility for the design and evaluation
of a large-scale change in clinical practices, working with and through other teams throughout
the facility. The relationships among these teams will be addressed in later sections.
This interdisciplinary team will have responsibility for overseeing the fall prevention program in
your organization, making key design decisions, working with unit-level teams to carry out

improvement activities, and monitoring progress. Thus, the implementation team will need some
members with clinical expertise and experience.
Successful teams have capable leaders who help define roles and responsibilities and keep the
team accountable for achieving its objectives. You will face a number of decisions in setting up
the team to lead the fall prevention program. In section 1, we discussed the process of choosing
someone to spearhead your fall prevention program, so that person should be identified and
involved in the discussion of these questions. Decisions that need to be made before convening
the team include:
How do we determine members of the Implementation Team?

How can we help the Implementation Team get started on its work?
2.1.1. Who should serve on the Implementation Team?

The most effective teams for overseeing a change project such as this one have several
characteristics:
An interdisciplinary team, including members from many areas with the necessary
expertise to address the problem. Senior leadership support is a prerequisite for system
change, but change itself comes most effectively from the ground up. Change happens as
teams that include frontline health care workers actively engage in high-priority problem
solving, such as redesigning processes of care. Including bedside staff as members will
be key to tapping their practical knowledge and engaging them in the change process.
Tool 2A (Interdisciplinary Team) provides a list of potential team members.
Strong link to leadership. While some organizations have found that the only way to
have adequate senior leadership support for an initiative is to include a senior leader on
the team, this may not be feasible or appropriate in every case. As an alternative, consider
asking senior leadership to designate a member of the top management team as the
champion for the fall prevention program. The teams leader should stay in frequent
contact with the senior leader champion and can approach that person when the team
encounters obstacles or needs access to senior leadership.
Link to quality improvement expertise. The Implementation Team will be strengthened
by having a member with expertise in systematic process improvement methods and in
team facilitation from the quality improvement or performance improvement department.
If your organization does not have a separate department with these functions, consider
using informal channels to identify a person with these skills to recruit to the team. In
some organizations, a member with improvement expertise successfully coleads the
Implementation Team with a clinical colleague.
Members who influence the areas that will need to be involved in fall prevention.
Sometimes it is not possible to anticipate every area that needs to be involved. It is
always possible to add team members later, but new members will need to be oriented to
the teams history and process.
You may find a checklist useful in considering potential team membership. Your list can include
the position/discipline, possible team members, and area of expertise.

The team member checklist can be found in Tools and Resources (Tool 2A,
Interdisciplinary Team).
This Institute for Healthcare Improvement Web site (Science of Improvement:

Forming the Team) provides both general principles for team composition and
several examples of different clinical improvement teams and their
membership:
www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementFormingt
heTeam.aspx).
Implementation Team Composition
Hospitals often find it very important that their team be truly interdisciplinary.
This composition ensures that as a group, they can understand fall prevention
from multiple perspectives and integrate hands-on knowledge and expertise
into their prevention efforts.
Hospitals find the Interdisciplinary Team tool (Tool 2A) useful to identify
additional Implementation Team members to invite to team meetings. For
example, hospitals use the tool to involve additional individuals with such roles
as risk manager, physical rehabilitation director, and pharmacist. Hospitals
report it is important to include senior leadership to help secure resources and
connect the team to other helpful staff and departments. Because hospitals are
organized differently, the exact titles and roles of the people you invite to the
team may be different from these examples.
2.1.2. How can you help the Implementation Team start its work?
Changing routine processes and procedures to alter the ways people conduct their everyday work
is a major challenge. Successful implementation teamsteams that achieve their goals and
sustain improved performancepay attention to the development of routines that make the
new practices for fall prevention better than existing practices. They identify and
implement new practices that are easier, more reproducible (not reliant on memory), and
more efficient than old practices.
The Implementation Team itself needs structure to achieve its objectives. Items to settle on early
include:
How often to meet (e.g., monthly).

Ground rules or guidelines for how to manage meeting time and for how to communicate,
both internally and externally.
Timeline for the teams work so that there is a shared understanding of the level of
urgency and priority this effort requires.

Consider:
How will the team do its work? This question refers both to the resources the team may
need (information, material) and to its methods of working. How will the team track
issues raised, explored, and addressed? How will the team assess current knowledge and
practice? How will the team use that information to redesign practice?
What is the teams agenda? This related question emphasizes the importance of giving
the team a clear charge and scope for its work. Can leadership provide team members
with a clear understanding of the short- and long-term goals and timeframes for the
implementation of improved fall prevention practices? For example, leadership may
provide the team with a written charge that specifies target dates and improvement goals.
Establish the scope of the Implementation Teams charge.

Develop a clear statement of the teams charge.
Ensure that senior leadership agrees with this charge.
Make sure that the team has access to the necessary tools and structures
to allow it to succeed.
Make sure that team members understand why they have been selected,
and find ways to recognize their efforts.
Ask the member from the quality improvement or performance
improvement department to orient the team to key principles and
approaches used in process redesign work.
Ensure that the team has the information it needs about the scope of the
problem of falls in your facility (e.g., fall rates, repeat fall rates, severity
of injury), the reasons for the teams work, and the expected outcomes.
Make sure the team meets regularly at the most convenient time and
place and that it meets often enough to make progress.
Develop a timetable for specific team tasks and assign members to be
responsible for completing those tasks.
Setting Aims) has guidance on setting team goals and other aspects of team
startup:
www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementSettingA
ims.aspx.
2.1.3. How does the Implementation Team work with other teams involved in fall
prevention?
The remainder of this section discusses activities that the Implementation Team will typically be
charged with, but the Implementation Team cannot carry out the entire program alone. The
Implementation Team will need to collaborate with at least the staff who provide routine patient
care in any unit where changes are to be implemented. These staff may be physically based on
the unit (e.g., nurses or nursing assistants) or may be assigned to work with specific units (e.g.,
rehabilitation therapists, pharmacists, or physicians). We call these staff the Unit Team. Both
teams have unique responsibilities but communicate and work together to make the program a
success.

The Implementation Team will look at the big picture, including strengths and opportunities in
current practices and the current status of prevention and fall incident reporting. This team will
then identify needed changes and the specific practices, tools, and resources needed to
implement these changes. Unit Teams, with members also represented on the Implementation
Team, will actually implement the changes, integrating them into existing workflows and
providing feedback about how the changes work. The Unit Team should include staff from all
shifts and will have ongoing responsibility for maintaining effective fall prevention practices.
No single team can make the program a success by itself. To help develop the Unit Team, the
Implementation Team should:
Outline roles for the Unit Team members that are clear and workable.
Consider each Unit Team members existing responsibilities on the unit and how the unit
team members new role interacts with those responsibilities.
Define what ongoing communication and reporting are needed and what the best linking
methods across the Unit Team and the Implementation Team might be. For instance, in
some organizations, Unit Champions provide this coordination function. Unit
Champions belong to both the Implementation Team and their own work units and thus
serve as critical communication links.
Keep in mind that there is more than one way to organize. A useful guide is to consider how
Implementation Teams for other clinical change efforts have operated successfully within your
organization. Your organizations quality improvement or performance improvement experts are
likely to have expertise in how to best organize and coordinate such teams. In many hospitals,
the training and development area may also be a resource for team organization expertise.
Clarify the Unit Teams roles in the change process.

Define the communication that is needed and the methods for linkages
across teams.
2.2. What needs to change and how do you need to redesign it?
In this section, we identify the steps the Implementation Team needs to take to assess the current
state of policy, procedures, and practice, and we indicate tools that may be useful in this process.
These steps are based on the principles of quality improvement, defined broadly to include
system redesign and process improvement. These methods are appropriate for an effort that seeks
to prevent falls by improving quality of care.
2.2.1. How do you start the work of redesign?

For the Implementation Team, the work of redesign has already begun through gathering the
information about organizational readiness (see section 1) and defining the teams members and
structure. This quality improvement process may already be familiar to your organization. If you
are not sure about the strength of your organizations quality improvement infrastructure, you
may want to complete Tool 2B, Quality Improvement Process.

Committees that oversee quality improvement for the hospital may go by different names, such
as Quality Council or Patient Safety Committee. If some of the quality improvement processes
listed in this inventory are not fully operational or present in your organization, you may need to
build your teams improvement capability. In addition to identifying team members with
improvement expertise, the Implementation Team can develop basic improvement skills through
an education process.
Improvement efforts tend to be most successful when teams follow a systematic approach to
analysis and implementation, and there are multiple approaches to consider. Team leaders and
members may want to consult more general resources for approaches to quality improvement
projects, such as information on the Plan, Do, Study, Act (PDSA) approach (described below in
Practice Insights).
If your organization already has well-established quality improvement processes and structures,
it will be beneficial to connect the fall prevention program with those processes. For example, if
you have an established reporting structure to leadership, including this program will help keep it
on the leadership agenda. If managers are already evaluated based on their quality improvement
efforts and results, making this program a part of the large quality improvement enterprise in
your organization will help ensure managers interest.
Assess your organizations current resources for quality improvement by

completing the quality improvement process inventory found in the Tools
and Resources section (Tool 2B, Quality Improvement Process).

Testing Changes) includes a brief summary of the PDSA cycle and a clinical
example of it in use:
www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementTestingC
hanges.aspx.

Examples of Improvement Processes
PDSA (Plan, Do, Study, Act)
PDSA is an iterative process based on the scientific method in which it is
assumed that not all information or factors are known at the outset; thus,
repeated cycles of change and evaluation will be needed to achieve the goal,
each cycle closer than the previous one. With the improved knowledge, you
may choose to refine or alter specific goals.
For more information, refer to Chapter 5 in the RAND report Putting Practice
Guidelines to Work in the Department of Defense Medical System. A Guide for
Action, available at www.rand.org/pubs/monograph_reports/2007/MR1267.pdf.
Johns Hopkins Translating Research Into Practice (TRIP) Model

This model elaborates a specific strategy for researchers, clinicians, and
managers to collaborate in quality improvement. The model uses 4 Es
(Engage, Educate, Execute, and Evaluate) and has been successfully applied in
both large-scale quality improvement (QI) collaboratives and small-scale,
clinically focused QI projects at the individual unit or hospital level. For more
information, refer to: Pronovost PJ, Berenholtz SM, Needham DM. Translating
evidence into practice: a model for large scale knowledge translation. BMJ
2008;337:a1714.
A practical case study applying this model at an individual unit level is

described in: Needham DM, Korupolu R. Rehabilitation quality improvement
in an intensive care unit setting: implementation of a quality improvement
model. Top Stroke Rehabil 2010;17(4)271-81.
Six Sigma
Developed at Motorola, Six Sigma methodology is based on the careful
analysis of data on process deviations from prespecified levels of quality and
use of redesign to bring about measurable changes in those rates. Six Sigma
incorporates a specific infrastructure of personnel with different levels of
training in the method (e.g., Champions, Black Belts) to take different roles
in the process. For more information, read What Is Six Sigma? at:
www.motorola.com/web/Business/_Moto_University/_Documents/_Static_File
s/What_is_SixSigma.pdf.
LEAN/Toyota Production System (TPS)

TPS is an integrated set of practices designed to systematically and
continuously identify problems at the point of production and empower
workers to identify and fix problems when they are identified. For more
information, refer toReducing Waste and Inefficiency in Health Care Through
Lean Process Redesign: Literature Review at
www.ahrq.gov/qual/leanprocess.htm.

Further reading relevant to quality improvement:
Rogers EM. Diffusion of innovations. New York: Free Press; 2003.

Langley GJ, Nolan TW, Provost LP, et al. The improvement guide: a
practical approach to enhancing organizational performance. 2d ed. San
Francisco: Jossey-Bass; 2009.
2.2.2. What is the current state of your fall prevention practice?

The work of redesign requires an assessment of your organizations current practices. In addition
to the tools suggested below, you may want to look ahead to section 5 for additional tools for
assessing current fall rates and care processes to prevent falls. We suggest looking carefully at
the gap between current practice and the recommended practices discussed in section 3. For
example:
Do any care processes already follow best practices?

Do others diverge in small ways or in major ways?
Which gaps are organizationwide, and which are specific to one or more units?
If your hospital is large and complex enough that you suspect variation in current practice across
units, the Implementation Team may want to start by focusing on one or two units.
Understanding the Organizational Context of Fall Prevention Practice

As a preliminary step in documenting prevention practices on the units, the team will need to
review the organizational context for the practices. Among the questions to consider:
Have there been prior efforts to improve fall prevention? If yes, are there lessons on
which you can build? For example, what supported those efforts? What barriers were
encountered and how can you avoid the same problems?
Are staff who prescribe and review medications (e.g., physicians and pharmacists)
involved in fall prevention practices? In what ways? What are their attitudes?
How are rehabilitation staff involved in fall prevention? In what ways do rehabilitation
staff and nurses coordinate their efforts to prevent falls?
How is information about patient fall risk factors documented and shared? What metrics,
if any, are currently used to assess organizational performance with respect to managing
these risk factors?
Understanding Current Processes on the Units

To change practice, it is critical to understand what the current practices are. The fact that fall
prevention has taken on new urgency reflects one or more perceived performance problems in
this area. Thus, it is important to identify any gaps between current best practices and actual
work practices. For example, staff may report a policy of accompanying all patients with
abnormal gait to the bathroom but may not always do this. The extent of these gaps is usually not
known until current practice is systematically examined. Understanding where any unit that is
targeted for change is starting from will help you identify gaps in knowledge and resources and
will allow you to see how much progress is made.

Process Mapping To Document Current Practices
One useful approach to understanding current practices is to use process mapping to examine
key processes where fall prevention activities could or should be happening. (Detailed
instructions on process mapping may be found in Tool 2C, Current Process Analysis).
Mapping can specify which organizational unit or person carried out each step in the process,
with particular attention to both the movement of the patient and the movement of information
about the patient. The goal of process mapping is to come to a common understanding of how a
particular care process is being carried out, which then leads to further discussion about how the
process should be carried out.
There are different approaches to process mapping, but each approach provides a systematic way
to examine each step in the delivery of a specific procedure or service. Experimentation with
different approaches can be helpful during the redesign planning phase because each approach
can provide different insights and answer different questions.
Integrating Change Into Current Work Routines

Beyond gap analysis and mapping of current practices, the team should consider how the
recommended practices for fall reduction can be integrated into current workflow and processes,
rather than layered on top of them. One way to approach this task is to systematically assess the
barriers to using evidence-based practices. For example, if eligible patients are not being
mobilized out of bed within a specific period of time from admission, what are the reasons? Is it
due to a lack of staff awareness that this should happen? Is it because nobody has specific
responsibility for this task? Is it because staff lack training in how to mobilize patients or
document that they did so?
Assess current practice on a sample of representative units to determine

which, if any, fall prevention practices are already in place (see sections
3 and 5). For example, is an initial risk factor assessment completed
within a certain timeframe of admission? Are the results used to
determine risk factors that can be intervened upon?
Use process mapping to describe current prevention practices and to
identify problem points. Process mapping will enhance understanding of
how and when fall prevention fits into existing processes such as
surgical or medical admissions, or admissions through the emergency
department.
Compare assessment results across units to determine which prevention
challenges are organizationwide and which may be unit specific.
Determine which practices need changing and consider how the new
practices can be built into ongoing routines (discussed in section 4.1).
This worksheet in Tools and Resources has a possible approach to process

mapping (Tool 2C, Current Process Analysis).
Use these worksheets to assess existing fall prevention practices in your facility
(Tool 2D, Assessing Current Fall Prevention Policies and Practices).

If you would like to learn more about process mapping, the AHRQ publication
Toolkit for Redesign in Healthcare provides a detailed example and data
collection tools, starting on page 14: www.ahrq.gov/qual/toolkit/toolkit.pdf.
2.2.3. What is the current state of staff knowledge about fall prevention?
Due to turnover, differences in training, and other factors, staff members will likely vary in their
knowledge of recommended fall prevention and treatment practices. To address these gaps
through education, you need to know what the gaps are. Thus, assessing the current state of staff
knowledge is critical.
One assessment tool is the Fall Knowledge Test (Tool 2E), which was developed through a
consensus process and used in a randomized controlled trial to measure nurses knowledge about
falls and their prevention (see box below for details).
By themselves, assessment of knowledge and training focused on increasing knowledge are not
enough. Training needs to be integrated with current work routines (see section 4.3.4). Based on
analysis of the knowledge test results, the team can assess barriers to change among the staff that
most likely will need to be addressed, a process that began with assessing their attitudes, as
suggested in section 1. These barriers can be discerned through the assessment of staff
knowledge and assessment of current practice. For instance, do staff believe that risk factor
assessment is unnecessary because preventive procedures are applied to everyone? Keep in
mind that not all barriers may be evident at the outset, so it is important to be attentive to
potential barriers as the first wave of changes are implemented.
Administer an inventory of fall prevention knowledge to staff members.

See the tool listed below for this task.
Consider collecting information on unit and occupation of respondents
so that you can use this information to analyze results and better target
training. Since this is an educational needs assessment, we do not
recommend asking staff to include their names, unless they want direct
feedback on their score. Using names may decrease participation.
Develop methods to correct knowledge gaps and misunderstandings.
The following tool can be used to assess staff knowledge:
Staff Knowledge Test (Tool 2E, Fall Knowledge Test).
A 14 multiple-choice question knowledge test was administered before and

after staff education following implementation of the Singapore Ministry of
Health Fall Prevention Clinical Practice Guideline.
For more details, refer to: Koh SLS, Hafizah N, Lee JY, et al. Impact of a fall
prevention programme in acute hospital settings in Singapore. Singapore Med J
2009;50(4):425-32.

2.3. How should goals and plans for change be developed?
2.3.1. What goals should you set?
Once the Implementation Team completes its analysis of the gaps in fall prevention, the team
will need to review the evidence on various best practices (discussed in section 3) that may help
address those gaps. However, before turning to those steps, the Implementation Team will need
to set goals for improvement. These goals should be related both to outcomes (e.g., a reduction in
falls per 1,000 bed days) and to processes (e.g., adherence to hourly rounds).
Goals should be related to data the hospital already collects or can collect (e.g., through incident
reports or a chart audit). External benchmarks should be used with caution, since fall rates vary
substantially by hospital unit (see section 5). Goal-setting will help determine the teams next
steps to redesign fall prevention activities within your hospital.
Once goals are chosen, your gap analysis may reveal problems in performance related to care
processes such as these:
Staff are not conducting the initial fall risk factor assessment within 24 hours of
admission.
Patients medications are rarely reviewed for fall risk.
Patients who are at risk for prolonged weakness from their hospital stay are not
mobilized within 48 hours of admission.
Patients with frequent toileting needs are not assisted in a timely fashion.
In this case, you may want to set goals related to the improvement of these measures to certain
levels within a certain timeframe, such as improving the number of at-risk patients who are
mobilized within 48 hours from 50 percent to 75 percent over the next 3 months. Alternatively,
you may find that after you examine staff knowledge, certain gaps should be addressed. Other
reasons for poor performance could be confusion in roles or a lack of staff communication. In
these cases, goals could be set for addressing and improving these issues within a certain
timeframe.
Set goals for improvement based on outcomes and processes.

Identify benchmarks against which to judge goals and progress.
Use goals to guide next steps in redesigning fall prevention.
2.3.2. How do you develop the plan for change?

Once goals have been set, the next step is to begin developing a more specific plan for
implementing new practices and for assessing that plan through the consistent collection and
analysis of data. This plan will be extended and refined by work to be completed in response to
additional questions (described in section 4).
While this plan will need to be flexible to meet the needs of specific units, a comprehensive plan
is still necessary. The best practices that will be discussed in section 3 are critical to the
implementation plan but are not enough, as they must be implemented within the context of
many other factors. Also, it is important to begin thinking early about sustaining the

improvements you put into place (as discussed in section 6). Thus, the implementation plan
should address:
o Membership and operation of the interdisciplinary Implementation Team.

o Standards of care and practice to be met.
o Ways gaps in staff education and competency will be addressed.
o Plans for rolling out new standards and practices, where needed.
o Staff accountable for monitoring the implementation.
o Ways changes in performance will be assessed.
o Ways this effort will be sustained.
The plan of action found in Tools and Resources can be a useful template for
developing your implementation plan (Tool 2F, Action Plan).
2.4. Checklist for managing change

The checklist for monitoring your progress on completing the managing
change activities can be found in Tools and Resources (Tool 2G, Managing
Change Checklist).

3. Which fall prevention practices do you
want to use?
Once you determine that you are ready for change, the
Implementation Team and Unit Team need to state their
plans for implementing best practices. In this section, best
practices are those care processes that, based on literature
and expert opinion, represent the best way we currently
know of preventing falls in the hospital.
Team members should reach consensus on the following

questions:
Which fall prevention practices should you use?

Which universal fall precautions should be applied
throughout the hospital?
How should a standardized assessment of fall risk
factors be conducted?
How should identified risk factors be used for fall
prevention care planning?
How should you assess and manage patients after a
fall?
How can your hospital incorporate these practices into a fall prevention program?
This section helps your organization address these questions. Further information regarding the
organization of care needed to implement these best practices is provided in section 4 and
additional clinical details are in Tools and Resources.
Recognize at the outset that implementing these best practices is a complex task. Some factors
that make fall prevention challenging include:
Fall prevention must be balanced with other priorities for the patient. The patient is
usually not in the hospital because of falls, so attention is naturally directed elsewhere.
Yet a fall in a sick patient can be disastrous and prolong the recovery process.
Fall prevention must be balanced with the need to mobilize patients. It may be
tempting to leave patients in bed to prevent falls, but patients need to transfer and
ambulate to maintain their strength and to avoid complications of bed rest.
Fall prevention is one of many activities needed to protect patients from harm
during their hospital stay. How should fall prevention be reinforced while maintaining
enthusiasm for other priorities, such as infection control?
Fall prevention is interdisciplinary. Nurses, physicians, pharmacists, physical
therapists, occupational therapists, patients, and families need to cooperate to prevent
falls. How should the right information about a patients fall risks get to the right member
of the team at the right time?
Fall prevention needs to be customized. Each patient has a different set of fall risk
factors, so care must thoughtfully address each patients unique needs.
Section 3: Best Practices 27

3.1. Which fall prevention practices should you use?
Given the complexity of fall prevention, the task of implementing a program may seem daunting.
To simplify things, we have broken down fall prevention activities into separate steps:
Universal fall precautions, including scheduled rounding protocols (section 3.2).

Standardized assessment of fall risk factors (section 3.3).
Care planning and interventions that address the identified risk factors within the overall
care plan for the patient (section 3.4).
Postfall procedures, including a clinical review and root cause analysis (section 3.5).
Your practices should be tailored to your organization. In addition, at the unit level, you should
cover these components in a manner tailored to the types of patients and care flow on each unit
(see section 3.6).
Your program is more likely to be successfully implemented and sustained when it is compatible
with hospital priorities and what is best for the patient. The hospitals first priority is acute
medical care; patients come to the hospital because they are ill and their primary purpose is to
receive treatment for their illness.
The goal of patient safety practices like fall prevention is to prevent additional harm to patients
while they are hospitalized. Hand hygiene to prevent spread of nosocomial infection is an
example of a patient safety practice that avoids patient harm without interfering with the
patients medical care. As you read through this section, think about how you can integrate your
fall prevention program with the variety of acute medical treatments that your hospital must
deliver.
Another key point to remember is that fall prevention alone cannot be the goal of a fall
prevention program. A theoretical example can illustrate this point. In theory, we could prevent
all falls by restraining all patients, thereby preventing them from leaving the bed (in actuality,
restraints may not prevent falls). But restraining patients would be unethical and represent poor
care. It would conflict with the principles of patient autonomy and cause all the complications of
bed rest, such as deconditioning, pressure ulcers, aspiration, and deep vein thrombosis, thereby
keeping the patient in the hospital longer and making it harder for the patient to recover.
This example illustrates how fall prevention programs need to be tied to the fundamental goal
that patient care improve each patients function and well-being. It also demonstrates that our
goal should be keeping fall and injury rates as low as possible, rather than getting to a zero fall
rate at the expense of other priorities. Fundamentally, fall prevention is about balancing multiple
priorities, as health itself is multifaceted.
Whatever set of recommended practices you select, you will need to take additional steps.
Section 4 describes strategies to ensure their successful implementation. The challenge to
improving care is how to get these key practices completed on a regular basis.

Understanding the causes of falls is important to developing your prevention
program. The classification system developed by Janice Morse is useful. Falls
can be classified into three types:
Physiological (anticipated). Most in-hospital falls belong to this category.

These are falls that occur in patients who have risk factors for falls that can be
identified in advance, such as altered mental status, abnormal gait, frequent
toileting needs, or high-risk medications. Key actions to take for prevention
include close supervision of the patient (see section 3.2) coupled with attempts
to address the patients risk factors (see sections 3.3 and 3.4).
Physiological (unanticipated). These are falls that occur in a patient who is

otherwise at low fall risk, because of an event whose timing could not be
anticipated, such as a seizure, stroke, or syncopal episode. Appropriate postfall
care (see section 3.5), coupled with injury prevention measures in the case of
recurrence (see section 3.4), are key for these patients.
Accidental. These falls occur in otherwise low-risk patients due to an

environmental hazard. Improving environmental safety will help reduce fall risk
in these patients but is helpful for all patients (see section 3.2).
For more information, see Morse JM, Tylko SJ, Dixon HA. Characteristics of
the fall-prone patient. Gerontologist 1987;27:516-22.
3.1.1. How are the different components of the fall prevention program related?
Each component of the fall prevention program is critical and each must be consistently well
performed. It is therefore important to understand how the different components are related. A
useful way to do this is by developing a clinical pathway.
A clinical pathway is a structured interdisciplinary plan of care designed to support the

implementation of clinical guidelines. It provides a guide for each step in the management of a
patient and reduces the possibility that busy clinicians will forget or overlook some important
component of evidence-based preventive care.
An example of a clinical pathway detailing the different components of a fall

prevention program is found in Tools and Resources (Tool 3A, Master
Clinical Pathway for Inpatient Falls). This tool can be used by the hospital
Unit Team in designing the new system, as a training tool for frontline staff,
and as an ongoing clinical reference tool on the units. This tool can be
modified, or a new one created, to meet the needs of your particular setting.
If you prepared a process map describing your current practices using Tool 2C,
you can compare that to desired practices outlined on the clinical pathway.

Implementing Fall Prevention Practices: Locally Relevant Considerations
Hospitals have experienced local challenges in trying to implement best

practices. Has your hospital experienced any of the challenges listed below?
This section of the toolkit will help to address these challenges.
Examples of challenges with risk assessment tools include:
Hospitals indicate that their current risk assessments do not sufficiently

cover some factors (e.g., medications, mobility).
The fall risk score is associated with a standard set of interventions that
is not customized to individual patients needs.
The current fall risk assessment results in almost all patients being
categorized as high risk for falls, which dilutes the value of this
designation with staff and their compliance with fall prevention
strategies.
Examples of challenges with specific interventions include:
Some medication order sets include medications that are known to have
a high risk for falls.
There is overreliance on bed alarms as a fall prevention strategy.
The use of various flags to indicate fall risk is so prevalent that their use
becomes ineffective.
Early mobilization may be compromised by extended bed rest orders
that are not discontinued.
3.2. What are universal fall precautions and how should they be implemented?
Universal fall precautions are the cornerstone of any hospital fall prevention program, because
they apply to all patients at all times. Implementing universal fall precautions requires training
all hospital staff who interact with patients, regardless of whether they are clinicians (covered
more in section 4). Implementation also requires that the importance of fall prevention become
embedded into the hospitals culture (covered in section 6).
3.2.1. What are universal fall precautions?

Universal fall precautions are called universal because they apply to all patients regardless of
fall risk. Universal fall precautions revolve around keeping the patients environment safe and
comfortable. Although the choice of which precautions to emphasize may vary by hospital, a
good starting list adapted from the Institute for Clinical Systems Improvement guideline (see
section 3.7) is provided here:
Familiarize the patient with the environment.

Have the patient demonstrate call light use.
Maintain call light within reach.
Keep the patient's personal possessions within patient safe reach.
Have sturdy handrails in patient bathrooms, room, and hallway.

Place the hospital bed in low position when a patient is resting in bed; raise bed to a
comfortable height when the patient is transferring out of bed.
Keep hospital bed brakes locked.
Keep wheelchair wheel locks in locked position when stationary.
Keep nonslip, comfortable, well-fitting footwear on the patient.
Use night lights or supplemental lighting.
Keep floor surfaces clean and dry. Clean up all spills promptly.
Keep patient care areas uncluttered.
Follow safe patient handling practices.
3.2.2. Why are universal fall precautions important?

Universal fall precautions constitute the basics of patient safety. They apply across all hospital
areas and help safeguard not only patients, but also visitors and staff in many cases. Maintaining
a safe and comfortable environment is the responsibility of the hospital independent of a
patients particular risks for falls, because failure to do so can put any patient at risk. For
example, virtually any patient could slip and fall if there is a spill on the floor.
3.2.3. How are universal fall precautions performed?

Universal fall precautions should be performed from both the standpoint of the patient and the
physical environment. For those precautions that require checking on the patient, such as making
sure the patients personal possessions are within reach, hourly rounding is an excellent basic
strategy. (Hourly rounding is typically defined as hourly visits between 6 a.m. and 10 p.m. and
visits every 2 hours between 10 p.m. and 6 a.m.; see Tool 3B, Scheduled Rounding Protocol).
Hourly rounding can be carried out by a nurse alternating with a nursing assistant (such as a
certified nurse assistant, patient care technician, or nurses aide). Patients are not disturbed if
sleeping, except as needed to provide care. Tool 3B, Scheduled Rounding Protocol, provides a
scripted approach to a strategy that can be used during bedside rounds. Called the 4 Ps or 5
Ps, it represents a set of items to mentally review when rounding on the patient. For example,
the 5 Ps could be:
Pain: Assess the patients pain level. Provide pain medicine if needed.
Personal Needs: Offer help using the toilet; offer hydration, offer nutrition, empty
commodes/urinals.
Position: Help the patient get into a comfortable position or turn immobile patients to
maintain skin integrity.
Placement: Make sure patients essential needs (call light, phone, reading material,
toileting equipment, etc.) are within easy reach.
Prevent Falls: Ask patient/family to put on call light if patient needs to get out of bed.
One benefit of hourly rounding is that it is proactive; it reduces patients need to use the call light
to ask for help and therefore decreases the number of unscheduled call lights that require
response. These regular rounds allow many needs like toileting and access to drinking water to
be met by staff who are scheduled to visit the patients room.

Hourly rounding has been carried out in different ways by different hospitals. Despite its
seeming simplicity, it requires careful planning to implement. See section 4 for strategies on
implementing new care processes at your hospital.
To read more about the evidence that supports hourly rounding, see:
Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit
Care 2009;18:581-4.
o
To read more about the challenges of implementing hourly
rounding, see: Deitrick LM, Baker K, Paxton H, et al. Hourly
rounding: challenges with implementation of an evidence-based
process. J Nurs Care Qual 2012;27:13-19.
Local Approaches to Implementing Scheduled Rounding
An opening and closing script for interaction with the patient is

provided. The closing script states, If you need a nurse before I come
back, use the call bell or contact the charge nurse at the phone number
on the white board.
Integrate 5 Ps into the rounding protocol.
Document completion of rounding on an hourly rounding tracking tool
kept in the patient rooms.
Conduct rounds every 2 hours between the hours of 10 p.m. and 6 a.m.
to let the patient sleep.
In addition to nursing staff, many different hospital staff members enter patients rooms
throughout the day, which provides additional opportunities to ensure that universal precautions
are followed. Having a member of senior management periodically tour hospital rooms to talk
with patients and see that their needs are being addressed is an excellent stimulus to frontline
staff to continue their efforts.
To cover environmental safety, regular environmental inspection rounds with nursing staff and
facilities engineers (Tool 3C) can be valuable. In between regular inspections, staff can use a
hazard reporting form (Tool 3D) to alert the unit manager to items that require fixing.
In addition to thinking about patient needs and environmental safety, remember to consider the
interaction of the patient with the environment. An environment that is safe for one patient may
not be safe for another. For example, a bathroom door may be wide enough for an independent
patient to enter but not wide enough for a patient with an assistive device, thereby putting the
latter patient at risk.
Another critical element of universal fall precautions is safe patient handling (Tool 3E, Clinical
Pathway for Safe Patient Handling). This is particularly important for patients who require
assistance with transfers. If staff members are not trained in safe patient handling, a patient could
fall or staff could be injured because appropriate assistive equipment was not used.

The following tools can be found in Tools and Resources:
Hourly rounding protocol to ensure that universal precautions are in

place (Tool 3B, Scheduled Rounding Protocol).
Inspection checklist for regular environmental rounds with nursing staff
and facilities engineers to identify and resolve environmental safety
issues (Tool 3C, Tool Covering Environmental Safety at the Bedside).
Hazard report form to alert the unit manager that items require fixing
(Tool 3D, Hazard Report Form).
A clinical pathway that illustrates appropriate application of safe patient

handling principles (Tool 3E, Clinical Pathway for Safe Patient Handling).
The way that hospitals are designed is an important part of reducing
fall risk. The Facilities Guidelines Institute (www.fgiguidelines.org )
provides guidelines for the design and construction of health care
facilities, including hospitals. Some design changes (e.g.,
recommendations for furniture) can be incorporated into existing
hospitals. The guidelines are available for purchase and are also
available for free reading at:
http://openpub.realread.com/rrserver/browser?title=/FGI/2010_Guideli
nes. A draft of updated guidelines (Guidelines for Design and
Construction of Hospitals and Outpatient Facilities) is also available at
the Facilities Guidelines Institute Web site:
www.fgiguidelines.net/comments/draft.php.
The Center for Health Design (www.healthdesign.org/) features
workshops and seminars on the relationship between hospital design
and patient safety.
One hospital found that performing an environmental inspection identified
stability problems with existing patient beds. The hospital was able to justify
implementation of a bed replacement plan in the subsequent year.
To read more about the evidence for improving hospital design, including safe
patient handling, see:
Sadler BL, Berry LL, Guenther R, et al. Fable hospital 2.0: the business
case for building better health care facilities. Hastings Cent Rep
2011;41:13-23.
3.2.4. How should universal fall precautions be documented?

Universal fall precautions can be documented in many ways, including progress note templates
in the chart and logs used for hourly rounding (hourly rounding is described in section 3.2.3).
Any documentation strategy should be carefully integrated into workflow, so as not to become
just another charting task.

3.2.5. What are some barriers to implementing universal fall precautions?
The rapid pace of activity in the hospital can be a barrier to implementing universal fall
precautions. Patients are frequently transported on and off the unit for tests and procedures. In
addition, patients may be required to change beds within the unit or be transferred to a new unit.
Every time a change occurs, universal fall precautions such as making sure the patients call light
is within reach and that the patient is oriented to his or her environment need to be reassessed.
Another barrier to implementing universal fall precautions is that some precautions require
patient understanding and cooperation. For example, patients may need to cooperate with using
appropriate footwear or using the call light when they need help. Patients who do not know their
own limitations may put themselves at risk for a fall despite the best efforts of hospital staff.
3.3. What is a standardized assessment of risk factors for falls, and how should
this assessment be conducted?
Assessing the patient for fall risks gives you the information you need to develop an
individualized care plan. There are multiple risk factors for falls, and different patients may have
different combinations of risk factors. These can change over time while a patient is in the
hospital. To identify the risk factors most important to the patients on your unit or in your
hospital, you need a system in place to ask the same key questions of each patient so that risks
are not missed. This can best be accomplished through a standardized assessment of fall risk
factors.
3.3.1. What is a standardized assessment of risk factors for falls?

After universal fall precautions, a standardized assessment of risk factors for falls is the next step
in fall prevention. By virtue of being ill, all patients are at risk for falls, but some patients are at
higher risk than others. Assessment of risk factors for falls is a standardized and ongoing
process with the goal of identifying patients risk factors, which can then be addressed in the
care plan.
3.3.2. Why is a standardized assessment of risk factors necessary?

Assessment of risk factors for falls is essential for a number of reasons:
It aids in clinical decisionmaking. Use of a standardized assessment helps ensure that

key risk factors are identified and therefore can be acted on.
It allows the targeting of preventive interventions to the correct patients. Fall
prevention is resource intensive. Resources should be targeted toward those who would
most benefit.
It facilitates care planning. Care plans can better focus on the specific dimensions that
place the patient at greatest risk.
It facilitates communication between health care workers and between care settings.
Workers have a common language by which they describe risk.
3.3.3. How is the assessment of risk factors performed?

An assessment of risk factors for falls is a standardized process that uses an assessment tool.
The tools evaluate several different dimensions of risk, including fall history, mobility,

medications, mental status, and continence. A tool could be a simple checklist of risk factors, or
it could be more complex, depending on the needs of the hospital or unit.
Because assessment is a defined task, clinicians can perceive that completing the assessment tool
is all they need to do. The Unit Team can help staff understand that these assessment tools are
only one small piece of the process. The risk assessment tools are meant to complement clinical
judgment, not to replace it.
Many other factors that are not listed in a typical risk factor assessment may be considered as
part of clinical judgment. In fact, specialized wards may need to collect additional risk factors as
part of their intake assessment. For example, on geriatric psychiatry wards, because of the
medications patients are taking, orthostatic hypotension may be an important fall risk factor (see
Tool 3F for instructions on measuring and evaluating orthostatic vital signs). However, for
consistency, we recommend that your hospital use a standard assessment tool throughout adult
units in the hospital as a foundation on which additional unit-level risk factors may be added.
This permits staff floating across different hospital units to share a common and familiar tool.
Key risk factors common to assessments include:
History of falls: All patients with a recent history of falls, such as a fall in the past 3
months, should be considered at higher risk for future falls.
Mobility problems and use of assistive devices: Patients who have problems with their
gait or require an assistive device (such as a cane or a walker) for mobility are more
likely to fall.
Medications: Patients on a large number of prescription medications, or patients taking
medicines that could cause sedation, confusion, impaired balance, or orthostatic blood
pressure changes are at higher risk for falls.
Mental status: Patients with delirium, dementia, or psychosis may be agitated and
confused, putting them at risk for falls.
Continence: Patients who have urinary frequency or who have frequent toileting needs
are at higher fall risk.
Other patient risks include being tethered to equipment, such as an IV pole, that could
cause the patient to trip; impairment in vision that could cause a patient not to see an
environmental hazard; and orthostatic hypotension, which could cause the patient to
become lightheaded or pass out when standing.
Instructions on measuring and evaluating orthostatic vital signs can found in the
Tools and Resources section (Tool 3F, Orthostatic Vital Sign Measurement).
3.3.4. What is the role of fall risk scores?

Assessment of risk factors for falls includes both the use of a standardized tool and an
assessment of other factors that may increase risk of falls. Which other factors to consider
beyond the standardized tool depend on clinical judgment and unit-specific policy.

Some tools that assess risk factors for falls also include a scoring system to predict risk for falls,
and many facilities plan care according to the amount of risk (according to high, moderate, and
low risk, for example). The problem with using the risk score to plan care is that the care plan is
not tailored to the individual patients risk factors. For example, two patients deemed high risk
by score might have different risk factors; one could have delirium, and the other could have
impaired gait. The responses to these risk factors need to be different. Trying to apply the same
care plan to all high risk patients may distract staff from implementing the elements of the care
plan that actually address each individual patients risk factors.
For these reasons, we think the most important application of an assessment tool is to identify
fall risk factors for which care plans can be developed. Because it takes time for a hospitals
culture to move away from relying on a summary score, we provide the scales in full here, but
we do not recommend excessive focus on the score.
Research has shown that scores from fall risk prediction tools do not actually
predict falls any better than a clinicians judgment. For this reason and others,
the creator of one commonly used scale (Tool 3G, STRATIFY Scale for
Identifying Fall Risk Factors) argues against the scores being used for
predictive purposes. For details, see:
Oliver D. Falls risk-prediction tools for hospital inpatients. Time to put them to
bed? Age Ageing 2008;37(3):248-50. Available at:
http://ageing.oxfordjournals.org/content/37/3/248.long.
3.3.5. Which assessment tools are used most often?

While some institutions have created their own tools, two tools have been studied most: the
Morse Fall Scale (Tool 3H) and the STRATIFY (Tool 3G). Both scales have established
reliability and validity. When used correctly, they provide valuable data to help plan care.
Because each hospital setting is unique, we do not take a position as to which scale you should
use. Also, these scales do not cover all key fall risk factors, so for your units needs, you may
have to supplement these tools with additional assessment items, such as those found in some of
the other tools covered in this section.
The Morse Falls Scale is made up of six subscales (history of falls, secondary diagnosis,
ambulatory aid, IV/heparin lock, gait, and mental status). The STRATIFY is made up of five
subscales (transfer/mobility, history of falls, vision, agitation, and toileting). Other scales may be
used instead of the Morse Falls Scale or the STRATIFY. The key point is to ensure that a
standard scale is used throughout adult units in the hospital, with additional risk factors assessed
as needed for specific units or as suggested by clinical judgment.
We also encourage you to review medications as part of fall risk assessment (see Tool 3I,
Medication Fall Risk Scale and Evaluation Tools). Strategies for reviewing medications will
depend on your hospital but may consist of a pharmacist reviewing medications for patients with
other risk factors or a nurse checking the patients medications against a standard list and
referring patients with a high-risk medication to a pharmacist. In either case, the pharmacist will
make recommendations back to the medical team regarding medications to discontinue or doses
to change.

Ask yourself and your team:
Do unit staff understand why they are assessing fall risk factors?
Do they systematically assess the most important risk factors for falls
among patients in your units?
For instructions on how to locally validate your preferred fall risk factor tool,
you can use this spreadsheet (How effective is your Falls Prediction Tool?)
on the UK Patient Safety First Web site:
www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-
support/Effectiveness%20tool%20v3.xls
Copies of the Morse and STRATIFY scales are included in Tools and
Resources (Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors, and
Tool 3G, STRATIFY Scale for Identifying Fall Risk Factors). The Morse
tool also has links to a training module.
Tool 3I, Medication Fall Risk Scale and Evaluation Tools, can be used to
identify medication-related risk factors for falls.
3.3.6. How should risk factors be assessed in pediatric populations?

The risk assessment tools described above are appropriate for the general adult population.
However, these tools may not work as well in differentiating the level of risk for hospitalized
children. Risk assessment tools exist for pediatric settings but they may not have been as
extensively validated as the Morse and STRATIFY scales.
For a review of pediatric assessment tools, see:
Harvey K, Kramlich D, Chapman J, et al. Exploring and evaluating

five paediatric falls assessment instruments and injury risk indicators:
an ambispective study in a tertiary care setting. J Nurs Manage
2010;18:531-41.
3.3.7. How often is the assessment of fall risk factors done?

Consider performing a fall risk assessment in general acute care settings on admission, on
transfer from one unit to another, with a significant change in a patients condition, or after a fall.
For patients with longer lengths of stay, performing a fall risk assessment at some regular
interval may be valuable. However, the optimal frequency of risk assessment is unclear and may
vary by unit.
Considering the specific patient situation, ask yourself and your team:
How often should the assessment of fall risk factors be done on your
unit?
How often is it actually being done?

3.3.8. How can we improve the accuracy of the fall risk factor assessment?
The accuracy of a risk factor assessment tool depends on the person using the tool. Experience
has shown significant variability among untrained staff even when evaluating the same patient.
The results of the fall risk factor assessment need to be trustworthy; otherwise, they will be
ignored. Therefore, training in how to complete the risk factor assessment is needed.
Check how risk factor assessment is performed on each unit:
Unit managers can look at the patient record and see if the risk factors
identified have been consistent (see Tool 5B, Assessing Fall
Prevention Care Processes). Wide fluctuations in risk factors are
unusual in stable patients. Similarly, when there is a major change in
clinical condition, check whether the patients risk factors have
changed.
Select a patient and see if the assessment is accurate. Staff may give the
patient the benefit of the doubt and underreport the number of risk
factors.
A training module developed by the Partners HealthCare System Fall
Prevention Task Force on proper use of the Morse Fall Scale may be found at
www.brighamandwomens.org/Patients_Visitors/pcs/nursing/nursinged/Medic
al/FALLS/Fall_TIPS_Toolkit_MFS%20Training%20Module.pdf. In addition
to the module, training should include real cases where the provider conducts
an assessment. Mental status and gait parameters require actual assessment of
a real patient (as opposed to a chart review by itself).
Please fill out the Partners HealthCare Morse Fall Scale Competency Request
Form at www.brighamandwomens.org/Patients_Visitors/pcs/nursing/
nursinged/Medical/FALLS/Permissions/PHS%20MFS%20Competency.pdf
prior to use.
Learn more about risk assessment:
Oliver D, Healey F. Falls risk prediction tools for hospital inpatients:

do they work? Nursing Times 2009;105:18-21. Available at:
www.nursingtimes.net/nursing-practice-clinical-research/falls-risk-
prediction-tools-for-hospital-inpatients-do-they-
work/1999146.article.
3.4. How should identified risk factors be used for fall prevention care planning?
Knowing which patients have risk factors for falls is not enough; you must do something about
it. Care planning guides what you will do to prevent falls. Once risk assessment has helped
identify patient risk factors, care planning should match the identified risks. This includes
planning for any risks found on the risk factor assessment tool, such as mobility challenges,
medications, mental status, and continence needs. It also includes planning around a patients
personal risks that may not have been captured by the assessment tool.

3.4.1. What is fall prevention care planning?
Fall prevention care planning is a process by which the patients risk assessment information is
translated into an action plan to address the identified patient needs. These are the patient-
specific actions that, in addition to the universal precautions described in 3.2, aim to prevent
falls. Care plannings specific purpose is to identify specific care practices that will be
implemented so that the patient is less likely to fall during the hospitalization.
Care planning accounts for multiple factors that pertain to the patients problems, and the
clinician therefore must synthesize multiple types of clinical data rather than just relying on one
specific piece of information. Because each patient has a unique risk profile that needs to be
integrated with care for the condition that caused hospitalization, the care plan should be
individualized for each patient.
A carefully written care plan is a document that ensures continuity of care by all staff members.
In addition, it can keep the patient safe and comfortable and can be used to educate the patient
and family prior to discharge. The care plan is an active document. It needs to incorporate the
patients response to the interventions as well as any changes in his or her condition.
3.4.2. How should care planning address risk of falls?

The care plan indicates specific actions that should, or should not, be performed. All care
planning needs to be individualized to fit the patients needs. Each risk factor should have a
corresponding plan of care.
There are many interventions available to prevent falls and fall-related injuries that you can
implement based on the patients specific risk factors. Below we list some of the major
categories, by risk factor, that you can consider in your care plan, with electronic resources
where appropriate.
Altered Mental Status

Patients with altered mental status should be assessed for delirium (Tool 3J, Delirium
Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion
Assessment Method). Trained nurses or physicians can carry out a delirium assessment. If the
patient is found to be delirious, a medical provider should evaluate the patient for causes, such as
infections, medications, and electrolyte imbalances. But it is more effective to prevent delirium
than to treat it. Delirium prevention may be an important part of the care plan for units that have
patients at high risk for delirium (e.g., patients with hip fractures, advanced age, or baseline
dementia, for example). Delirium prevention protocols are available on the Hospital Elder Life
Program (HELP) Web site at no cost after registration:
www.hospitalelderlifeprogram.org/public/public-main.php.viii
For cognitively impaired patients who are agitated or trying to wander, more intense supervision
(e.g., sitter or checks every 15 minutes) may be needed. These patients should have their
medications reviewed, as medications can both contribute to agitation as well as help calm
viii
These materials are copyright protected, and all forms or their adaptations should acknowledge: 2000, Hospital
Elder Life Program, LLC. The user assumes all risk for use of the materials.

patients whose agitation is a threat to themselves or others or is interfering with the delivery of
necessary care.
We do not recommend bed alarms for the purpose of fall prevention in cognitively impaired
patients. Unless the patient can be rescued rapidly after the bed alarm goes off, the patient may
be able to exit the bed well before anyone can come to help. One large trial of bed alarms failed
to show a benefit for prevention of falls.ix
Assess whether patients with altered mental status are delirious and therefore
require further medical evaluation for delirium using the delirium evaluation
bundle found in the Tools and Resources section (Tool 3J, Delirium
Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire,
and Confusion Assessment Method).
Safety Zones:A Strategy for Supervising Cognitively Impaired Patients
Some hospital units have designated areas for patients at high fall risk. These
areas have enhanced staffing to observe patients more closely. One hospital
implemented this strategy using safety zones, which consisted of four patient
rooms in each unit with one dedicated staff member responsible for those
patients. The staff member checks on the patients every 15 minutes. These
rooms are designated for cognitively impaired patients requiring (1) closer
supervision, and (2) specialty equipment and activities.
Safety zone room equipment includes low beds, mats for each side of the bed,
night light, gait belt, and a STOP sign to remind patients not to get up. This
model was originally implemented as a less costly alternative to the hospitals
patient sitter program. The hospital reports the program has been successful in
reducing fall rates and improving patient and family satisfaction.
Impaired Gait or Mobility

Patients with impaired gait or mobility will need assistance with mobility during their hospital
stay. All patients should have any needed assistive devices, such as canes or walkers, in good
repair at the bedside and within safe reach. If patients bring their assistive devices from home,
staff should make sure these devices are safe for use in the hospital environment. Even with
assistive devices, patients may need help from staff for mobility.
Patients with impaired mobility fall into three groups:
Patients without mobility problems at home who were admitted to the hospital for a non-
mobility-related reason (e.g., pneumonia). Some of these patients are at risk for
deconditioning during their hospital stay, which can cause weakness and loss of mobility.
These at-risk patients should participate in a mobility program. The HELP Web site
includes information about a mobility program for use by trained volunteers,
ix
Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in
hospitalized patients. Ann Intern Med 2012;157(10):692-9.

companions, or nursing aides.For appropriate patients admitted for non-mobility-related
reasons, this program can help maintain mobility and decrease the risk of deconditioning
during hospitalization.
Patients who enter the hospital with a prior mobility deficit (e.g., from Parkinsons
disease) but who are admitted for a non-mobility-related reason. Depending on the
severity of the mobility deficit, these patients can be handled through physical or
occupational therapy or through a mobility program. Tool 3K, Algorithm for Mobilizing
Patients, provides an algorithm for determining whom to include in a mobility program.
Patients who were admitted to the hospital for a procedure that directly affects their
mobility (e.g., total knee replacement) or a medical event that affects their mobility (e.g.,
acute stroke). These patients should be seen by a physical or occupational therapist.
A sample algorithm for mobilization of patients can found in the Tools and
Resources section (Tool 3K, Algorithm for Mobilizing Patients).
To read more about the Hospital Elder Life Program, which offers strategies
for developing a volunteer-based mobility program, go to
www.hospitalelderlifeprogram.org/public/public-main.php.
Registration is required to access the program manuals:

www.hospitalelderlifeprogram.org/pdf/Clinical%20Manual.pdf (Hospital
Elder Life Program Organizational and Procedural Manual, The Clinical
Process)
and
www.hospitalelderlifeprogram.org/pdf/Volunteer%20manual.pdf (Hospital
Elder Life Program Volunteer Training Manual).
Mobility programs have been shown to decrease hospital length of stay and
costs, and increase the likelihood that a patient is discharged home rather than
to a nursing home or rehabilitation facility. For details, see: De Morton NA,
Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients.
Cochrane Database Syst Rev 2007 Jan 24(1):CD005955.
Frequent Toileting Needs

Patients with frequent toileting needs should be taken to the toilet on a regular basis, via a
scheduled rounding protocol (for example, see Tool 3B).
Visual Impairment
Patients with visual impairment should have corrective lenses easily within reach.

High-Risk Medications
Patients on high-risk medications (see Tool 3I, Medication Fall Risk Scale and Evaluation
Tools) should have those medications reviewed by a pharmacist with fall risk in mind.
Recommendations made to the treating provider for discontinuation, substitution, or dose
adjustment. If a pharmacist is not immediately available, the treating provider should carry out
the medication review.
The medication review may sometimes indicate that the patient needs to stay on a medication
that increases the risk for falls because the benefits outweigh the risks, but the important point is
that fall risk was considered. In addition, each hospital may need to develop its own approach to
pharmacist-physician communication around medications to ensure that physicians carefully
consider pharmacists recommendations.
Units with a high proportion of patients on medications that cause orthostatic hypotension, such
as psychotropic medications, may want to use a protocol for checking and reporting orthostatic
vital signs (see Tool 3F). Finally, the patient and patients family should be alerted and educated
about fall risk and steps to prevent falls when the patient is taking these medications.
If you have an electronic health record, be cautious about using computerized

alerts to identify medications that put the patients at high risk for falls. If these
alerts occur too frequently or inappropriately, they will be ignored. We
recommend targeting the alerts to the specific population of interest and
carefully pilot testing alerts with providers before a full-scale rollout.
Frequent Falls
Patients with frequent falls should have their injury risk assessed. This assessment should include
checking for a history of osteoporosis, including prior low-trauma fractures or osteoporosis noted
on a bone mineral density test. Although the effects are long term, treatment for osteoporosis
should be considered if the patient is not already on treatment. Also, the patients physical
environment should be reviewed to reduce the risk of injury (e.g., making sure the patients bed
is set low when the patient is resting in bed).
In hospital units known to have a high prevalence of patients at risk for injury after a fall,
consider making an injury risk assessment part of the admission evaluation. For thorough
coverage of options to prevent fall-related injuries, go to the VA Sunshine Healthcare Network
(VISN 8) Patient Safety Center of Inquiry Web site at
www.visn8.va.gov/visn8/patientsafetycenter/fallsTeam/default.asp.
3.4.3. How should patients and families be involved in the care plan?
Patients and their families should understand the patients fall risk and how the proposed care
plan addresses this risk. Specific aspects of the care plan that patients and families can help
implement should be identified. If learning needs have been identified, teaching to address
knowledge gaps can occur.

Use of educational resources, such as written materials appropriate to language and reading level
(see Tool 3L, Patient and Family Education), can augment but not replace instruction. Patients
and their significant others need to understand the potential consequences of not following a
recommended prevention care plan as well as feasible alternatives and possible outcomes.
Every patient has the right to refuse the care designated in the care plan. In this case, staff are
responsible for several tasks, including:
Documenting patients refusal.

Trying to discover the basis for the patients refusal.
Presenting a rationale for why the intervention is important.
Designing and offering an alternative plan and documenting the patients response,
including the patients comprehension of all options presented. This alternative strategy
needs to be described in the care plan and documented in the patients medical record.
A sample initial fall prevention care plan for a patient that you can
integrate into your overall care plan is available in Tools and Resources
(Tool 3M, Sample Care Plan).
A sample patient/family education pamphlet on the care plan is also
available (Tool 3L, Patient and Family Education).
Patient Education
One hospital trains volunteers to provide fall prevention education to patients.

Each volunteer spends 5-10 minutes visiting each patient every Monday,
Wednesday, and Friday to review the fall prevention handout. This education
is supplemental reinforcement and does not replace education provided by the
nursing staff.
3.4.4. How should the risk factor assessment and care plan be documented and
communicated?
Document fall risk factors, and interventions to address those risk factors, in the care plan.
Documentation of care planning ensures continuity of care and staff knowledge of what should
be done for the patient. Most hospitals choose to have a dedicated care plan form within the
medical record. The care plan helps all staff members to be aware of a patients risks.
Consider the following strategies to enhance awareness of fall risk factors and appropriate
documentation:
Incorporating fall risk factors and interventions in daily patient flowsheets.

Including a discussion of fall risk factors and interventions as part of patient report or
handover.
Creating an automated daily report at the unit level that identifies which patients on the
unit have which risk factors and which interventions are needed for those patients.
Because many of the risk factors for falls are important for other aspects of good care (e.g.,
mental status, continence status), try to set up a documentation system where the risk factor

information is collected as part of a broader assessment of the patients needs. That way, you
only have to collect and document the information once.
Remember that while medical record documentation is necessary, it alone will not be sufficient.
Communicating the patients risk factors should occur orally at shift change, and by review of
the written material in the medical record or patient care worksheet. The oral shift handoff
should include any change in fall risk factors during the shift, including relevant medication
changes, and should incorporate findings from hourly rounding.
The following article describes an effort to communicate a patients specific fall

prevention needs by posting, above the head of the bed, icons that identify
specific fall risk factors:
Hurley AC, Dykes PC, Carroll DL, et al. Fall TIP: validation of icons to
communicate fall risk status and tailored interventions to prevent patient falls.
Stud Health Technol Inform 2009;146:455-9.
Be thoughtful about the use of color-coded nonskid socks, magnets, and
wristbands to identify patients at high risk for falls. In some units where
virtually all patients are at high risk for falls, these cues may simply be
ignored.
Patients demonstrating particularly high risk behaviors can be discussed as part of the units
safety huddle (or safety briefing). A safety huddle is a short, informal meeting to cover issues
related to patient safety. The safety huddle can be enhanced by a standard report (preferably
gathered electronically) that summarizes which patients on the unit have which risk factors for
falls.
To read more about safety huddles, visit the VA VISN 8 Patient Safety Center of
Inquiry Web site at
www.visn8.va.gov/VISN8/PatientSafetyCenter/safePtHandling/safetyhuddle_02
1110.pdf.
Read more on the Pennsylvania Patient Safety Authority Web site about the
risks and benefits of communicating high fall risk with colored wristbands,
which are often used for this purpose:
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/wristband
s/Pages/home.aspx
In addition to shift change, medical rounds are an opportunity for interdisciplinary

communication. For example, pharmacists may attend these rounds and provide an update to
medical providers about medications that put the patient at higher risk of falls. Or, if attendance
on rounds is not possible, pharmacists can place recommendations to change drug therapy as a
consult note in the medical record.

Mobility programs that combine services of nursing and rehabilitation personnel offer another
example of interdisciplinary communication and collaboration. Nursing assistants mobilize
patients at risk for deconditioning who are in the hospital for non-mobility-related reasons.
Physical or occupational therapists see patients with a need for skilled care or with weight-
bearing limitations. See the resource box titled One Hospitals Approach to Maintaining Patient
Mobility in section 6.4 for details.
Remember that the fall prevention component of the care plan needs to be updated periodically
to be accurate. The care plan needs to be reassessed when a patients risk factors are reassessed
and are found to have changed. Typically this is when a patient changes units, has a change in
health status, or has a change in medication associated with increased risk of falls. These updates
also need to be followed up by a change in your actual care practices for the patient.
Check whether the fall prevention component of the care plan is being updated
appropriately on your unit.
Read more about how one hospital developed a ticket to ride that
summarized key aspects of the care plan for patients who needed to be
transported between the unit and procedural areas. The ticket was designed
to ensure a smooth handoff of care:
Pesanka DA, Greenhouse PK, Rack LL, et al. Ticket to ride: reducing
handoff risk during hospital patient transport. J Nurs Care Qual
2009;24:109-15.
3.4.5. What are barriers to care planning and solutions to these barriers?
Sometimes, putting together all the discrete parts of a care plan based on patient risk factors can
be akin to putting together a puzzle. It takes time and the ability to see the whole picture, and it
definitely requires patience and skill. There are many potential barriers to accurately completing
care planning. Some that should be considered include:
Time: Acuity of the patient population may mean the staffs time must be spent at the
bedside and the development and documentation of care planning is delayed, thus
increasing the chances of missed information.
Expertise: Staff may not have the needed expertise to know which interventions to
include or what they can do without a health care providers order.
Value of care plan: There may be a prevailing attitude that taking the time to write the
care plan is not a priority. This is a unit or facility culture issue that needs to be addressed
systemwide.
Responsibility: The plan of care should be interdisciplinary. It is not just the nursing
staff who develop and implement treatment plans. Physical and occupational therapists,
pharmacists, and others are important contributors to fall prevention and need to be an
integral component of the care planning process.

Information technology: Some facilities have computerized charting that prompts care
planning based on risk. These care plans may not be sufficiently individualized to the
needs of the patient. With other systems, staff have to go to multiple screens, which can
be time consuming and increases the chance of overlooking key elements.
Some solutions to the barriers above include:
Using or creating systems that make care planning more streamlined by linking to the
admission and followup fall risk factor assessments. Computer systems that tie
assessment results directly to the care plan can provide useful decision support to staff, as
long as the systems are flexible in allowing individualized care planning. For example,
patients who are newly identified as at risk due to mobility problems may generate an
automatic order for a physical therapy consult or a mobilization protocol, avoiding delays
arising from care planning.
Linking the care plan to routine practice. The plan of care, including addressing fall
risk factors, should be routinely included in shift reports and patient handoffs. Prompts
may be needed at first to incorporate the prevention program into everyday care practices.
Read more about how one health care system that uses an electronic health
record developed a new system of tailored fall prevention care plans and
overcame anticipated barriers through careful usability testing:
Zuyev L, Benoit AN, Chang FY, et al. Tailored prevention of

inpatient falls: development and usability testing of the fall TIPS
toolkit. Comput Inform Nurs 2011;29:TC21-8.
3.5. How should you assess and manage patients after a fall?
Despite our best efforts, patients will nonetheless fall. Some may even sustain an injury. When a
fall happens, you will need to carefully assess the patient for any injuries in a systematic way.
After the patients needs are attended to, you need to document your findings in the medical
record and complete an incident report.
In this section we highlight some elements of a careful clinical review for injuries and also
discuss conducting a root cause analysis to understand the causes of the fall. An understanding of
the events surrounding a fall can inform the care plan for the patient who fell, as well as guide
ongoing quality improvement efforts at the unit level. Using data on falls to monitor your
improvement efforts is discussed in more detail in section 5.
3.5.1. What is a postfall clinical review?

A postfall clinical review is a structured way to collect information after a fall. The clinical
review aims to determine whether there are injuries or other complications (Tool 3N, Postfall
Assessment, Clinical Review). The clinical review focuses on immediate risk of injury or
complications. Depending on the type of fall and patient comorbidities, including clotting
disorders and use of anticoagulants, the clinical review may include assessment for injury, serial
neurologic exams, and a fresh fall risk factor assessment. The new assessment will include
medication review and ordering of laboratory tests.

3.5.2. How is the clinical review performed?
Key components of the clinical reviewx include:
Checks for signs or symptoms of fracture or potential for spinal injury before the patient
is moved.
Safe manual handling methods for patients with signs or symptoms of fracture or
potential for spinal injury.
Regular neurologic observations for all patients where head injury has occurred or cannot
be excluded (e.g., unwitnessed falls).
Medical evaluation, with an expedited examination of patients who have signs of serious
injury or high vulnerability to injury or have been immobilized.
Details on how to perform the clinical review can be found in Tools and
Resources (Tool 3N, Postfall Assessment, Clinical Review).
For tools and resources on safe patient handling, see the VA VISN 8 Web page
on safe patient handling and movement:
www.visn8.va.gov/VISN8/PatientSafetyCenter/safePtHandling/
3.5.3. What is a root cause analysis?

Root cause analysis is used in organizations to evaluate and understand what problems
contributed to error or undesired outcomes. After a fall, you will collect data to reconstruct the
event and determine the causes of and contributing factors to the fall (Tool 3O, Postfall
Assessment for Root Cause Analysis). The data collection will obtain information that may help
prevent the next fall in this patient or future patients. The postfall assessment for root cause
analysis captures information from the patient, staff, and other witnesses about how the fall
occurred. For more on root cause analysis, see section 5.1.6.
Details on how to perform a root cause analysis can be found in Tools and
Resources (Tool 3O, Postfall Assessment for Root Cause Analysis).
x
Adapted from the U.K. National Patient Safety Agency, Essential care after an inpatient fall. Available at:
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=94054&type=full&servicetype=Attachment

3.5.4. How are the clinical review and root cause analysis documented and
communicated?
Many components of the clinical review and root cause analysis overlap. For example,
understanding the circumstances of the patients fall can assist in assessing the patient for
injuries, while also being important for understanding potential causes. You may need to adapt
Tools 3N and 3O to your hospitals specific needs.
Documenting and communicating the clinical review are critical to the patients safety, because a
medical provider may need to take action based on the assessment, such as ordering lab tests or
imaging studies or changing medications. In cases of falls with significant trauma, the patient
may need to be taken to surgery. An oral handoff to the treating medical provider is therefore
essential.
Careful documentation and communication of your root cause analysis are critical to preventing
future falls in the same patient. For example, if a patient was given a sedative overnight for
insomnia and then fell due to being drowsy, the entire treating team (including nursing,
pharmacy, and medical provider) needs to know what happened. That way, they will not
prescribe the sedative again to that patient or future patients in similar circumstances. After a fall
occurs and the patients root cause analysis is complete, a safety huddle (see section 3.4.4) may
be appropriate so that the whole unit can learn from the event.
With frequent handoffs between hospital personnel, whether it be nursing staff who change shift
every 8 hours, or hospitalists who rotate every week and have separate night or weekend
coverage, communication is critical. The care plan discussed in section 3.4 (see also Tool 3M,
Sample Care Plan) is an ideal place to document findings from the clinical review that the unit
team should keep in mind throughout the hospital stay.
If applicable, the patients risk factor profile can also be updated electronically by a designated
member of the unit team to reflect the recent fall and any new risk factors that were discovered.
For more information about what information should go into the hospitals incident reporting
system, see section 5.
3.5.5. What are challenges to performing the clinical review and root cause
analysis?
There are significant challenges to performing a good clinical review and root cause analysis:
Many falls are unwitnessed, and the patient may not be able to provide accurate
information about what occurred.
Falls often occur due to the confluence of multiple risks, which makes it difficult to
identify a smoking gun. For example, a new medication may interact with a patients
underlying cognitive or mobility limitations to precipitate a fall.
A good root cause analysis requires input from multiple team members, and it may be
difficult to assemble them rapidly.
Time to perform a root cause analysis may be limited, especially at certain busy times of
the day, such as at change of shift. Having a standard protocol, as described in 3.5.6
below, may address this challenge.

3.5.6. How can performance of postfall assessments be improved?
Performance of postfall assessments, whether for clinical review or root cause analysis, may be
improved by having a standard protocol and ensuring that this protocol is easily accessible to
staff on the unit. Also, the information gathered on the assessment tool should contain all the
information needed to file an incident report (see section 5) so that information does not need to
be gathered twice. In settings where a medical provider makes scheduled rounds, having a nurse
or pharmacist join rounds to discuss potential culprit medications related to the fall may improve
the assessment process.
Read more about how one hospital used a dedicated fall evaluation service to
improve postfall assessment:
Shorr RI, Mion LC, Chandler AM, et al., Improving the capture of
fall events in hospitals: combining a service for evaluating inpatient
falls with an incident report system. J Am Geriatr Soc 2008;56:701-4.
A modified version of the tool used in this study is presented as Tool 3O.
3.6. How can your hospital incorporate these practices into a fall prevention
program?
In section 3, we have outlined best practices in fall prevention that you can use to improve your
fall prevention program. Research evidence suggests that your program is most likely to succeed
when it addresses multiple components, including universal precautions (section 3.2), risk factor
assessment (section 3.3), care planning (section 3.4), and postfall assessment (section 3.5).
However, it may not be possible to tackle all these elements at once. In addition, you may want
to include additional items beyond what is discussed here. Some of these items can be identified
through the use of additional guidelines (see section 3.7).
In addition to creating a program that is tailored to your hospital, you will need to customize the
fall prevention program to each unit due to patient acuity and specific individual circumstances.
Thus, it is important to identify fall risk factors that are more prevalent on each specific unit. For
example, a neurology unit may have a high proportion of cognitively impaired patients requiring
closer monitoring. A rehabilitation unit may have a high number of patients with mobility
problems. Other units may have patients whose needs fluctuate rapidly or involve frequent
patient transport. These include the emergency department, observation units for patients staying
less than 24 hours in the hospital, and radiology. In addition, pediatric patients have special
assessment tools, as discussed in section 3.3.5.
Identify the units that will require customization of the fall prevention
program.
Adapt your program to meet the needs of the specific units.

Examples from some hospital units addressing fall prevention. Note that some of
these examples include activities that may be applicable to other units as well.
Geri-psych unit:
Direct line of sight to patients.
1:1 staff assignment for selected patients
Rounds every 15 minutes.
Annual fall prevention education for staff.
Routine assessment and documentation of orthostatic blood pressure and pulse changes.
Medical unit:
Nurses assess whether patient has a mobility deficit and request a physician order for a physical
therapy consult if needed.
The unit also uses patient sitters if a patient has had a fall.
Patientsare moved near the nurses station if they do not follow instructions to get assistance to
get out of bed.
Pharmacists review medication profiles of patients. Triggers in computerized physician order
entry provide an alert indicating high fall risk for various medications. Pharmacy tries to
eliminate medications with high fall risk from formulary.
Patient care technicians take patients to the bathroom.
Physical therapist or nurse shows patient how to use mobility aid.
Inpatient rehab:
Interdisciplinary care planning includes nursing, occupational therapy, physical therapy, speech
therapy, dietary, nurse practitioner, and social services.
Nurse practitioner has responsibility for trying to wean patients off narcotics, and clinical
pharmacist consult is ordered if needed.
Pharmacy reviews each patients medication profile within 24 hours of admission.
Some patients are placed in safety zone (semiprivate rooms with a patient care observer on
duty; see section 3.4.2).
Rehab aide is available to assist patients in ambulating during the day. Nurses assist during the
evening and on weekends.
Delirium prevention efforts include pharmacist review of patient medication profile, infection
control program, and environmental factors.
Neurology and/or postneurosurgical units:
For high-risk patients, a computerized evaluation is conducted to determine required assistance
with mobility aids or use of lift equipment. Decisions from evaluation are posted on white board
in patient room.
Floor has a dedicated physical therapist. If PT consult is ordered, PT determines progressive
ambulation needs and fall prevention interventions are customized.
Interventions for patients with cognitive deficits include involving more staff in care planning,
asking family to stay with patient, and moving patient closer to the nurses station.
Nurses and physicians work together to evaluate medications that interfere with neurologic
exam and alter patients fall risk status.
Physician is actively involved with delirium prevention, including avoidance of medications
that may contribute to delirium.
Pharmacy reviews medication profile for each patient.

Read more about preventing falls in radiology in an article released by the
Pennsylvania Patient Safety Authority: Falls in radiology: establishing a unit-
specific prevention program. Pa Patient Saf Advis 2011 Mar;8(1):12-7.
Available at:
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/mar8(
1)/Pages/12.aspx.
3.7. What additional resources are available to identify best practices for fall
prevention?
A number of guidelines have been published describing best practices for fall prevention in
hospitals. These guidelines can be important resources for improving fall prevention programs.
Prevention of falls and fall injuries in the older adult. Nursing best practice
how to guidelines. Toronto: Registered Nurses Association of Ontario;
2005. Available at: www.rnao.org/Page.asp?PageID=924&ContentID=810.
Boushon B, Nielsen G, Quigley P, et al. Transforming care at the bedside
how-to guide: reducing patient injuries from falls. Cambridge, MA:
Institute for Healthcare Improvement; 2008. Available after free
registration at:
www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientI
njuriesfromFalls.aspx.
The How to guide for reducing harm from falls. London, UK: Patient
Safety First; 2009. Available at:
www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaign-
news/current/Howtoguidefalls/
Guidebook for preventing falls and harm from falls in older people:
Australian hospitals. Sydney, NSW: Australian Commission on Safety and
Quality in Healthcare; 2009. Available at:
www.activeandhealthy.nsw.gov.au/assets/pdf/Hospital_Guidebook.pdf
Health care protocol: prevention of falls (acute care). 2d ed. Bloomington,
MN: Institute for Clinical Systems Improvement; April 2010. Available at:
www.icsi.org/falls__acute_care___prevention_of__protocol_/falls__acute_
care___prevention_of__protocol__24255.html.
3.8. Checklist for best practices

Once you have read through this section, use the checklist for best practices to monitor your
progress on completing the activities that have been described here.
The checklist for best practices can be found in Tools and Resources (Tool 3P,
Best Practices Checklist).

4. How do you implement the fall
prevention program in your organization?
Now you are ready to begin implementing the fall
prevention practices you have identified. No matter how
good your fall prevention program is in concept, if it is not
used by the staff it will not be successful. To this point, you
have looked at your organizations readiness to improve fall
prevention (section 1); assessed needs, set goals, and begun
preparing for change (section 2); and examined best
practices (section 3). In this section, the Implementation
Team will work with the Unit Teams to implement the new
prevention practices at the frontline care level.
Your organization may already be using some of the best

practices that you have identified for implementation, but
other practices will involve changes in the way you
complete tasks. For the new set of practices to be fully
implemented and sustained, it will need to be customized to
your organization and integrated into ongoing work
processes.
The questions in this section will guide you in multiple aspects of implementation. To
successfully implement your change program, you should answer three sets of questions:
What roles and responsibilities will staff have in preventing falls?
How do you assign roles and responsibilities?

What role will the Unit Team play?
What role will the Unit Champions play?
How should the prevention work be organized at the unit level?
What fall prevention practices go beyond the unit?

How do you put the new practices into operation?
How do you manage the change process at the front line?

How do you pilot test the new practices?
How do you get staff engaged and excited about fall prevention?
How can you help staff learn new practices?
Section 4: Implement Practices 52

Implementing Best Practices: Locally Relevant Considerations
Implementing best practices requires attention to detail. Some issues that may
need to be sorted out at your hospital include:
Education of clinical and nonclinical staff:
o Reaching all nurses with fall prevention education, particularly night

shift and weekend staff.
o Providing fall prevention training for professional disciplines
beyond nursing staff and rehabilitation services (e.g., pharmacy,
physicians, medical residents) or for nonclinical staff (e.g.,
environmental services, transport team).
Communication of fall risk:
o Developing mechanisms for the emergency department to

communicate a patients risk factors for falls to the admitting
department.
Improving handoff tools between departments and between shifts.
This section will address these types of challenges.
4.1. What roles and responsibilities will staff have in preventing falls?
In section 2 you examined current practices and identified aspects needing improvement; in
section 3 you reviewed best practices. Now you need to define specifically what needs to change
to implement the best practices you have chosen and to decide who is going to do what. Specific
areas of responsibility and paths of communication and accountability will be needed.
Hospitals and units within them vary in their staffing patterns and usual ways of doing business.
You will need to consider staff roles based on the features of your organization overall and the
individual units involved in fall prevention. The Implementation Team will need to involve
members of the Unit Team, especially the unit managers, in these decisions.
Staff roles should be clearly defined so that Unit Team members will understand if and how their
roles will change. If you, as the Implementation Team leader, will implement the fall prevention
program with current staff, you will need to take their skills and strengths into account in
allocating responsibilities. You will need to consider not only what individual responsibilities
are, but also how the roles interact and what ongoing communication and reporting are needed.
The questions below will guide you through the process of considering and specifying the roles
and responsibilities of the unit staff and Unit Champion. The questions also will guide you in
deciding how best to organize work at the unit level and how to customize the set of practices for
specific work units in your organization.

4.1.1. How do you assign roles and responsibilities?
Think about who will perform each specific task identified for your chosen set of best practices.
Responsibilities should be assigned based on the relevant formal training and informal work
experience of each profession or individual. In some cases, a group will perform a task based on
their specific role or title, such as certified nursing assistants (CNAs). Other tasks may be
assigned to a specific individual. In that case, always make sure you have a backup; it is
important that everyone knows who the backup is when the assigned individual is unavailable.
As you work through this section, you should consider taking each task required to implement
your chosen fall prevention practices and entering it into the summary page of the worksheet
provided as Tool 4A, Assigning Responsibilities for Using Best Practices, in Tools and
Resources. Then assign specific individuals or groups to each task. Sections 4.1.2 through 4.1.4
include examples of responsibilities different staff might take on; those examples are
summarized in Tool 4B, Staff Roles. In making these assignments, make sure you work with
the unit manager or Unit Champions from the units in which you are implementing change.
In Tools and Resources, you can find a worksheet to use in deciding how
responsibilities will be assigned in your organization (Tool 4A, Assigning
Responsibilities for Using Best Practices) together with a summary page
illustrating how responsibilities might be organized (Tool 4B, Staff Roles).
4.1.2. What role will members of the Unit Team play?

The Unit Team consists of staff members who provide daily direct patient care by conducting
fall risk assessments, planning care for fall prevention, and ensuring that care is performed and
documented. In other words, they are responsible for the performance of your set of best
practices. In most cases, the Unit Team will include everyone on the unit, such as RN, LPN,
CNA, medical staff, pharmacist, physical therapist/occupational therapist, and other staff
assigned to a unit on a regular basis.
The types of staff working in your hospital may differ from these. You will need to assign roles
appropriate to your staffing configuration. An example of the allocation of roles between nurses,
aides, and other staff is shown below. It is important to be clear on what roles have or have not
changed and what is permitted in each States practice acts.

Nurse
Completes and documents fall risk assessments.

Monitors progress or changes in medical condition.
Documents care and prevention practices.
Reports patient problems to medical provider.
Obtains consults and medical orders as needed.
Educates patient and family as appropriate.
Supervises aides.
Knows how to obtain needed supplies and/or equipment (e.g., walker).
Nurse aide
Evaluates the safety of the patients environment during care tasks.

Performs appropriate care plan tasks.
Reports task completion to the nurse.
Reports any changes in the patients condition to the nurse.
Treating medical provider
Reviews need for specific types of rehabilitation therapy.

Writes orders for specific interventions, including activity orders.
Reviews medications for fall risk and makes changes to medications as
needed.
Pharmacist
Reviews medication list of patients at high risk based on medication

profile.
Suggests alternative medications or dosing regimens to medical
provider.
Physical or occupational therapist
Provides skilled therapy to patient to improve ability to perform

activities of daily living, such as ambulation and transfers or bathing and
dressing.
Makes recommendations for assistive devices or adaptive equipment.
Trains patient in safe use of assistive devices or adaptive equipment.
Reviews appropriateness of activity orders and asks medical provider to
review and/or adjust activity orders as needed.
Special attention is required when temporary staff rotate onto the unit. They will not be aware of
how care is organized on the unit and what their critical role is in fall prevention. Given how
frequently temporary staff work on most hospital units, unit managers should develop plans in
advance so that temporary staff can be rapidly oriented to their exact roles on the team. Make

sure you have a plan in place for temporary staff and can provide appropriate monitoring and
assistance.
Define the roles for all members of the Unit Team. Worksheet 4A in
Tools and Resources may help in this process. You may need to tailor
roles to accommodate differences in staffing and practices in different
units.
Develop a plan for orienting and monitoring temporary staff.
Be sure staff roles you have developed are in compliance with your
State practice acts.
Highlight which of these responsibilities will differ from the Unit Team
members current roles and therefore will require changes in practice.
These will require special attention as you manage implementation of
the new set of practices (described in section 4.2).
If you anticipate barriers to unit staff filling the defined roles, highlight
them for use in planning your change strategies (described in section
4.2).
4.1.3. What role will the Unit Champions play?

Many successful improvement efforts have relied on Unit Champions as critical members of the
Unit Team, especially during the implementation process. A Unit Champion is a staff member
who serves as the liaison between the Implementation Team and the unit staff. The Unit
Champion is someone who is familiar with the program goals, care processes, and outcome data
that will be used. He or she is often the initial go to person when staff have questions.
The Unit Champion posts results, reports on program progress, and provides updates in staff
meetings. He or she helps conduct outcome audits. Most important, the Unit Champion is often
the cheerleader who encourages staff during the difficult implementation process. A Unit
Champion may be anyone who works on the unit, including nurses (RN, LPN) and nurse aides.
Ideally, there should be at least one champion per shift to provide guidance to other staff.
However, the number of champions should be customized to fit the needs of your hospital.
The role of the Unit Champion can be temporary and only needed for getting the program
started. Once practices are routinized, the champion may not be needed. However, maintaining a
go to person may help with program sustainability and ease introduction of additional changes
or modifications.
Another approach that has been used successfully is to have several staff on the unit serve as fall
prevention resources without the formal title of Unit Champion. This has occurred when
frontline staff have become engaged in and excited about fall prevention, usually as a result of
their early involvement in improvement efforts. While this approach may not have the public
visibility of a Unit Champion, it brings the benefits of engaging more staff and embedding
knowledge of good prevention practices more deeply in each unit. The characteristics of these
individuals and their roles would be similar to the Unit Champions during the improvement
process, and these people would remain in place after fall prevention activities have become
routine.

Look for these characteristics in your Unit Champions and resource staff:
Satisfactory level of performance.

Excellent communication skills.
Effective linkage to other staff members.
Respect from their peers.
Enthusiasm for patient safety.
A demonstrated positive image of their unit.
Good problem-solving skills.
Knowledge of the benefits and process of fall prevention.
Ability to collaborate with all key stakeholders in the improvement
process.
Tool 4B, Staff Roles, and Tool 4A, Assigning Responsibilities for Using Best
Practices, in Tools and Resources may help you define the role of Unit
Champions and resource staff.
4.1.4. How should the fall prevention program be organized at the unit level?
While the definition of team member roles is the first step in determining how the fall prevention
program will be carried out, how to organize the work is also key: What are the paths of ongoing
communication and reporting, including the lines of oversight and accountability? What
documentation is needed and to whom is it submitted? How will fall prevention be integrated
with ongoing work processes?
The mapping of current processes and analyses of gaps from best practices that you did earlier
(described in section 2.2.2) will help address these questions. The earlier work will help you
identify the key points of communication and accountability that need to be addressed and to
highlight problem areas that require special attention.
What paths of ongoing communication and reporting will be used?

Communication needs to occur between staff at all levels: within the unit (e.g., between nurses,
nurses and aides, nurses and physicians, nurses and other staff) and between unit staff, the
Implementation Team, and senior management. Communication around clinical issues related to
fall prevention is covered in further detail in section 3. Here, we talk about what kind of
communication is needed to ensure that the new work processes decided on by the
Implementation Team are carried out as intended. We also discuss how to obtain feedback from
unit staff on changes that may be needed to the implementation plan.
A variety of strategies can be used to communicate about how changes that are being
implemented are actually going. Unit Champions can present updates on the implementation of
new changes at regularly scheduled meetings of the Implementation Team. Alternatively, unit
managers can provide updates based on information they gather from their staff. The key aspects
are that the communication processes occur regularly and thoroughly with the least amount of
time and effort.

How will fall prevention be integrated into ongoing work processes?
Building new fall prevention practices into ongoing work processes is necessary for
sustainability. Strategies for building prevention into ongoing processes include:
Making certain procedures universal so that staff do not have to decide which patients
they apply to (such as the universal fall precautions discussed in section 3),
Integrating communication regarding fall risk into regular communication, such as shift
handoffs, and
Creating visual cues or reminders in physical locations, such as logos indicating elements
of the fall risk care plan (e.g., assistance with toileting) above the patients bed.
Examples of How Change Can Be Incorporated Into Routine Care

A newly admitted patient automatically triggers a medication review
using the pharmacy risk scale (Tool 3I) to determine whether a full
pharmacy evaluation of the medication list should occur.
A standard order set is used for all patients to institute appropriate
mobilization protocols (Tool 3K).
Patients noted to have a change in mental status automatically receive
the standard Delirium Evaluation Bundle (Tool 3J) to determine the
need for increased supervision and further medical evaluation.
A postfall assessment note (Tool 3O) is created as a structured
electronic template or paper progress note to guide nurses through the
appropriate care processes.
Hourly rounds (Tool 3B) are used to assess toileting needs alongside
other concerns.
Environmental rounds occur on a regularly scheduled basis by a
hospitalwide team to ensure environmental safety (see Tool 3C for
checklist).
Many hospitals are now using electronic health records, which provide additional opportunities
to integrate best practices into the daily routine. For hospitals that have electronic records,
questions to consider include:
What information about fall risk factors is already part of the patient record?
Are data already in the system that can be used as part of a new process to assess fall risk
factors?
What is the most logical place in the record to collect/organize/assess information about
patient fall risk factors and any necessary precautions?

Suggestions for Building Fall Prevention Into Electronic Documentation
Systems
Features that can be added to electronic documentation systems include:
Automatic consults to physical therapists for mobilization as directed

by a mobilization protocol, or to occupational therapists for patients
who need retraining to perform an activity of daily living.
Automatic consults to pharmacists if medication risk score exceeds a
threshold.
Patient education booklet linked to the documentation system so that
it is readily available if needed.
Fall prevention guidelines or quick reference text integrated into the
computer charting system.
Fall risk factor report that summarizes which patients on the unit have
specific risk factors.
Working from the process map for fall prevention and gap analysis you
developed for your organization in the redesign process (section 2.3), develop
your individualized operating rules to specify:
Paths of ongoing communication and reporting.

Lines of oversight and accountability.
Documentation that is needed and people to whom it is submitted.
Strategies for integrating fall prevention into ongoing work processes.
These rules should include not only regular activities, but also contingencies,
such as plans for supervising very high risk patients if a sitter is not available.
Consistent with those decisions, complete the worksheet provided as

Tool 4A in Tools and Resources to assign specific individuals or
groups to each task.
Determine which changes in practice, if any, will require changes in
formal hospital policies and procedures.
4.2. What fall prevention practices go beyond the unit?

Our focus in this toolkit is primarily on preventing falls at the unit level. However, as you
organize the unit work, you should think beyond the unit in two ways. First, consider how
information about fall risks is conveyed in handing off patients to other units or when
discharging patients. Handoffs are generally weak links in our systems. Important questions to
ask regarding handoffs include:
When patients are transferred from the hospital ward to radiology for a test, is the person
doing the transport alerted to the patients fall risk?
What is the strategy for handling patients who are admitted through the emergency
department because of a fall?

On discharge, do patients and families have input into the postdischarge care plan? Are
they given information about how to prevent falls in the home, and are referrals made for
additional services and supports, such as home physical or occupational therapy, as
needed?
Second, consider how the interactions of other hospital staff with patients could contribute to the
observation and care of patients on the unit. For example, orderlies who transport patients on and
off the unit can assist in care by ensuring that their transfer techniques are consistent with
standards of practice (see Tool 3E, Clinical Pathway for Safe Patient Handling). Dietary staff
who distribute and collect trays can provide information about whether the patient has had poor
oral intake, thereby increasing risk for volume depletion. In addition, dietary and environmental
staff can report if a patient asks to use the toilet or if patients are sitting in a position that puts
them at risk for falling, such as at the edge of a wheelchair.
4.3. How do you put the new practices into operation?

Once you determine which fall prevention practices (described in section 3) to implement and
how to define roles and organize work to carry out those practices at the care level in the units
(described in section 4.1), you will need to develop strategies to put the practices into action. In
this section, we focus on pilot testing and initial implementation of the new practices. In section
6, we will move to sustaining your improvement efforts.
To guide the changes that will be needed, you should consider four questions:
How do you manage the change process at the front line?

How do you pilot test the new practices?
How do you get staff engaged and excited about fall prevention?
How can you help staff learn new practices?
4.3.1. How do you manage the change process at the front line?
As highlighted in earlier sections, incorporating the new set of practices will involve changes in
the way people do their work, which is often difficult. In some cases the changes will be minor,
but in others they will be substantial. Therefore, to make the needed changes:
Ensure that staff understand their new roles, know why the new roles are important, and
have the knowledge and tools to carry out their roles.
Help reduce resistance to change by ensuring that staff understand the reasons for change
and agree that change is needed.
To help staff accept the new set of practices fully, ensure that they understand that those
practices offer promising strategies for providing high-quality care for patients and that
such care is a priority for their supervisors.
Identify and minimize practical barriers to using the new practices, such as inadequate
access to supplies or equipment. For example, assistive devices, low beds, and floormats
should be stored on or near the unit for easy availability.
At all levels, engage staff to gain their support and buy-in to the improvement effort and
help tailor the practices in fall prevention.

To manage the change process effectively, the Implementation Team will guide, coordinate, and
support the implementation effort during the pilot phase and as the new prevention practices are
rolled out across the hospital. The Implementation Team will work with the Unit Champions
described in section 4.1.3 or with others designated as the unit-level lead for this improvement
effort. They will need to work in a variety of areas, discussed below.
Involving staff, clinicians, and middle managers

At the unit level, it will be important to involve not only frontline nurses and support staff but
also nurse managers and physicians. In section 1 we discussed the importance of leadership
support for improvement efforts. The focus then was on senior leadership, but support of middle
managers is also needed. For example, nurse managers and service chiefs should be involved in
early discussions about how the new set of practices will be introduced and strongly supported in
their units.
Physician involvement is often overlooked in fall prevention but needs to be encouraged. Make
sure physicians are aware of best practices in fall prevention and hospital policies and
procedures. This is particularly true for aspects of care that physicians may need to be involved
in, such as medication changes, activity orders, or physical/occupational therapy referrals.
Monitoring implementation progress

The Implementation Team and Unit Champions should develop a process for ongoing
monitoring of implementation progress. Part of the process will be gathering feedback from staff
and clinicians. For example, Unit Champions can compile questions and problems from staff to
send back to the Implementation Team.
In addition, the monitoring process should include tracking changes in fall rates and care
processes to prevent falls, as described in section 5. Results should be communicated to staff and
to the Implementation Team. The information loop should be closed by having the
Implementation Team report to the unit what it did with the information the unit provided.
Sustaining management support

Above the unit level, the Implementation Team should continue to keep senior leaders and
middle managers regularly informed about progress with the fall prevention program to sustain
their early support for the improvement effort. These individuals support will be needed during
implementation in multiple ways:
Leaders and managers are important sources of communication. Their expressed support
for improving fall prevention will reinforce its importance and thus increase the impetus
among staff to adhere to the new practices.
Leaders and managers can help remove barriers across departments. While the
Implementation Team by design should include all divisions affected by fall prevention,
some issues may not be resolved within the Implementation Team but need to be taken to
a higher level of authority. This will be particularly important if your organization does
not have a strong history of quality improvement that gives staff and managers on the
improvement team authority to change procedures as needed.

Senior leaders may need to authorize resources for the prevention initiatives. In the pilot
and early implementation phases, the Implementation Team may need, for example, to
negotiate with administration (and unit managers) to secure release time for Unit
Champions and for staff training. Managements financial support will be needed, for
example, if new equipment (e.g., low beds) is recommended in the program or if a fall
prevention campaign needs visibility tools such as posters or buttons. You initially
considered resource needs for fall prevention in section 1.6. Consider reviewing this list
and updating it if needed.
Building on the work from earlier sections, refine your Implementation

Plan to outline the details of your strategies, including lead
responsibility and timelines, for managing change at the front line.
Clarify the roles of the Implementation Team and Unit Champions for
the implementation period. Communicate those roles to frontline staff
and leadership.
Confirm management support for the resources needed for hospitalwide
implementation in terms of (among other things):
o Expressed support for the initiative.

o Additional months for Implementation Team to work.
o Training resources and release time for the unit staff involved.
o Resources for equipment and supplies.
o Policies and procedures in place.
Develop a process for monitoring implementation closely and making

midcourse corrections as needed.
Carry out your strategies so that you successfully implement the new
practices.
4.3.2. How do you pilot test the new practices?

In starting the implementation process, many organizations begin the rollout of new practices in
one or two units before launching them across the hospital. Pilot testing will allow you to
identify and work out any problems in the recommended practices and processes at an early
stage and thus refine the program to better fit your hospital before the entire launch. It also can
generate early success that will build momentum for later spread across the organization.
Small hospitals may have only a few units, so a formal pilot may not be practical. If so, it is still
important to consider a trial period where you get feedback and allow for program refinements. It
can bring the same advantages of a more formal pilot in identifying problems and customizing
the set of prevention practices to fit your hospital needs early in the implementation process.
To begin the pilot, you should choose one or two units to participate. Different criteria may be
applied to select the units. You may identify one unit that was successful with a past
improvement project and one that was not so successful. You may use a unit with low fall rates
and a unit with high fall rates, or units that present different implementation challenges, such as a
medical/surgical unit and a geriatric psychiatry unit.

By selecting several very different units, your Implementation Team can hear from the Unit
Champions and staff what they like and any problems they have had implementing the program.
Two widely different units will give you a better overall feel for refinement that may be needed
and ways to answer staff questions that arise.
You will also need to decide what information you will want to collect and from that decide how
long to try out the new set of practices. The pilot test can provide two types of information:
1. The items you will collect to judge the pilots success, such as completing fall risk factor
assessments, including fall prevention in care plans, or improving adherence to care
plans; and
2. Feedback from participants on how the new practices are working in terms of, for
example, the clarity of what is expected from staff or the impact of the new practices on
staff workflow. Section 5 provides tools that will help in measuring care processes and
outcomes.
You should use information from the pilot to change the fall prevention program to meet your
hospitals needs and to change the ways the program is introduced to staff. You also can use the
pilot to identify additional staff barriers to change.
Rather than designing the pilot like a research project where the interventionin this case the
new fall prevention practicesis held constant for the duration of the test period, consider
conducting a formative pilot in which changes are made as needed during the pilot to maximize
the likelihood of success. In this case, pilot information will be provided to the participating
units, Unit Champions, and the Implementation Team on a regular basis throughout the pilot
period, rather than simply after it has been completed. Minor modifications can be made along
the way and their impact followed within the pilot phase.
Design and conduct the pilot, making changes as needed if that is your
chosen approach.
Compile staff questions and problems that arose to guide changes and
analyze measures of success.
Communicate the results to the participating units, the Unit Champions,
the Implementation Team, and hospital leadership.
Refine the practices to address problems that surfaced in the pilot test.
Use the list of staff questions from the pilot units and the answers to
those questions to create an implementation tool for the hospitalwide
launch.
4.3.3. How do you get staff engaged and excited about fall prevention?
Engaging the buy-in and ongoing participation of staff members is particularly important for
staff who are involved in hands-on care and whose involvement will be needed to achieve the
improvement objectives. Each unit has its own culture; some people will be willing to try
something new and others will have difficulty or be unwilling to make any changes. To have any
program succeed, unit staff need to have input and be able to make suggestions on how to
individualize the program for their unit.

In preparation for the initial rollout or pilot testing on each unit, the Implementation Team or
Unit Champions should meet with unit staff on all shifts. They should review the newly defined
roles and responsibilities and work with staff to determine how to adjust roles and paths for
communication and reporting among staff on their unit. They also should discuss how to address
barriers to adherence.
This process can take place with a unit-level improvement team or with the entire staff, such as
at a regular staff meeting. A challenge in facilitating these discussions will be to distinguish
between constructive tailoring that will enhance adherence to the new set of practices and
weakening of the new practices to reflect reluctance to change or failure to accept them.
Even with involvement in tailoring the changes to their unit or position, some clinicians and staff
may be reluctant to use the new set of practices. Strategies for dealing with such reluctance will
depend on a number of factors, including the stage of implementation, the positions of and
number of people resisting, and the reasons for and strength of resistance.
If reluctance, or active resistance, is localized to specific parts of the hospital or to specific

individuals, you may decide not to include those units or individuals in the early implementation.
Focus instead on the units and people with the greatest interest and highest likelihood of success.
Their early success may convince others that the new set of practices is worth using. Or as
implementation advances and the new practices become the norm, peer pressure may spur
resisters to change their minds.
Including fall prevention in staff performance evaluations can formalize the new practices as the
norm and enhance commitment. If resistance during early implementation is widespread, you
will need to understand why. Then you can either redesign the set of practices or implementation
strategy to accommodate the resisters concerns or reconsider your earlier conclusion that the
hospital is ready for this change. If the latter, you may want to continue to use the new program
in volunteer units until you can build a successful case for hospitalwide use.

Identify implementation strategies that have worked successfully in
your hospital before or that sound promising based on the way things
are done in your organization.
o Consider whether your organization uses big, visible campaigns to

introduce new initiatives, or is more comfortable with lower key
incremental change.
o Review staff engagement materials from other health care
organizations and from past quality improvement efforts at your
hospital.
o Based on your hospitals culture, history, and values, begin to
identify the characteristics of an approach that would engage staff
members at large.
Develop strategies for working with staff at the unit level to get staff
input in tailoring the new practices to their units and reducing barriers;
include all shifts in this process.
From staff input and earlier analyses of current practices, identify
potential barriers to uptake of new practices, including staff resistance
to change, and develop strategies to remove or work around them.
Develop plans for ongoing communication about the progress,
successes, and challenges of the change efforts at multiple levels of the
organization.
Examples of Strategies That May Help To Reduce Staff Resistance
Continue to persuade staff that fall prevention is important:
o It is a standard of care and a nurse-sensitive issue.

o It is a reportable event and a highly visible indicator of safety and
quality.
o Hospitals will not be reimbursed by Medicare for hospital-acquired
falls with trauma.
Involve staff in defining the problems and testing solutions so they feel
ownership of the changes and see the success that can result.
Provide staff with data (e.g., through staff meetings, unit bulletin
boards, and email) that initially highlight the problem of high fall rates
and later show success in preventing them.

Examples of methods and strategies to increase staff engagement can be found
in a recent critical care nursing journal article.* Key points from this article
include:
A brief elevator speech to describe to staff, in a nutshell, why the fall

prevention program was important.
Surveys of staff and physicians regarding what they felt were
successful strategies for fall prevention on the unit in question.
Multiple inservices and staff reminders about the fall prevention
program.
The presence of an enthusiastic clinical champion with adequate
resources and leadership support.
5. * Gutierrez F, Smith K. Reducing falls on a definitive observation unit: an Evidence-

Based Practice Institute Consortium Project. Crit Care Nurs Q 2008;31;127-39.
4.3.4. How can you help staff learn new practices?

Once the initial pilot test has been completed, you will have information about areas in which
education is required to enhance staff knowledge. This aspect, while valuable, is not enough to
change practices. Staff members also need help figuring out how to integrate their new
knowledge into their existing practice and how to replace existing practices and skills that may
be less effective with others that are more effective. Thus, a variety of methods for sharing
information about new practices is needed.
Adult learning theory suggests that adults learn best through methods that build on their own
experiences. Since individuals have different learning styles and are at different levels of practice
proficiency, a variety of educational approaches is best, including, but not limited to, the
following:
Didactic methods can include a variety of formats, such as lectures, interactive

presentations, online lessons, case study analysis, listserv discussion, and grand rounds
talks.
Care practice simulations, expert practitioner observation of care delivery, and
competency validation also can enhance learning.
Clinical bedside rounds and patient case review are excellent ways to translate abstract
knowledge into behavior changes.
Any and all plans for new or changed staff education should be worked out in close collaboration
with your existing content experts on fall prevention. As discussed in section 6, learning will
need to be supported on an ongoing basis, both as refreshers for existing staff and as training for
new staff.

Choose appropriate settings for staff education about best practices in
fall prevention and the changes that will be needed to incorporate those
practices in this organization, consistent with adult learning principles.
For example, combine traditional training sessions, individual coaching,
or ongoing discussion in staff meetings.
Work with your staff education department and other key stakeholders
(e.g., residency directors) to interpret the results of the staff fall
prevention knowledge assessment (Tool 2E, Fall Knowledge Test)
and to develop an educational strategy. We have suggested a number of
materials to use throughout this document that can be found in Tools
and Resources.
To assess current staff education practices, complete the checklist found in
Tools and Resources (Tool 4C, Assessing Staff Education and Training).
The Registered Nurses Association of Ontario Web site offers a model

curriculum to use for staff education (Falls Prevention: Building the
Foundations for Patient Safety, a Self-Learning Package):
http://rnao.ca/sites/rnao-ca/files/Falls_Prevention_-
_Building_the_Foundations_for_Patient_Safety._A_Self_Learning_Pac
kage.pdf
A range of resources, including many that can be used for staff
education, may be found at the Veterans Affairs National Center for
Patient Safety falls toolkit Web site:
www.patientsafety.gov/SafetyTopics/fallstoolkit/index.html
The AHRQ-sponsored Falls Management Program (focused on nursing
homes) includes a variety of educational content that can be adapted for
hospitals. To learn more, go to
www.ahrq.gov/research/ltc/fallspx/fallspxman5.htm.
4.4. Checklist for implementing best practices

The checklist for implementing best practices can be found in Tools and
Resources (Tool 4D, Implementing Best Practices Checklist).

5. How do you measure fall rates and fall
prevention practices?
A basic principle of quality measurement is: If you cant
measure it, you cant improve it. Therefore, fall rates and
fall prevention practices must be counted and tracked as
one component of a quality improvement program. By
tracking performance, you will know whether care is
improving, staying the same, or worsening in response to
efforts to change practice. Moreover, continued monitoring
will help you understand where you are starting from and
whether your improvement gains are being sustained.
During the course of your fall prevention improvement

effort and on an ongoing basis, you should regularly assess
your fall rates and fall prevention practices. 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).
The questions below will help you and your organization develop measures to track fall rates and
fall prevention practices:
How do you measure fall and fall-related injury rates?

How do you measure fall prevention practices?
Measuring Fall Rates and Fall Prevention Practices: Locally Relevant

Considerations
Your hospitals may experience challenges in trying to measure fall rates and
fall prevention practices, such as:
Revising incident reports to include more specific fields for contributing

factors to falls (e.g., high-risk medications, which medications).
Finding mechanisms to communicate fall incident report information to
the Implementation Team.
Using process metrics to measure the adherence to fall prevention
strategies.
Spreading lessons learned from postfall safety huddles and root cause
analyses from one hospital unit to another.
This section will discuss these types of issues.
Section 5: Measure 68
5.1. How do you measure fall and fall-related injury rates?
5.1.1. Why measure fall and fall-related injury rates?
Fall and fall-related injury rates are the most direct measure of how well you are succeeding in
making patients safer related to falls. If your rates are improving, then you are likely doing a
good job in preventing falls and fall-related injuries. Conversely, if your fall and fall-related
injury rates are getting worse, then there might be areas in which care can be improved. You can
use these data to make a case for initiating a quality improvement effort and monitoring progress
to sustain your improvements.
5.1.2. What should be counted?

In measuring fall rates, you will need to count the number of falls and the number of occupied
bed days on your unit over a given period of time, such as 1 month or 3 months. To count falls
properly, people in your hospital or hospital unit need to agree on what counts as a fall.
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. Also, staff may feel pressure to underreport borderline cases because of
concern that their unit will compare poorly with other units. Therefore, when a uniform
definition of fall is shared throughout the hospital, it needs to be coupled with a culture of trust in
which reporting falls is encouraged. There are many definitions of falls, and you should choose
one appropriate for your situation.
You may also want to track the number of repeat falls on your unit. Sometimes a single repeat
faller can skew the fall rate for the entire unit, so knowing about repeat falls can be helpful in
understanding your data.
With each fall, you will need to define the level of injury that occurred, if any. Combining
information about falls with the level of injury can give you an injurious fall rate. The injurious
fall rate can be tracked just like the total fall rate. The advantage of the injurious fall rate is that it
tracks the more clinically important falls and is less likely to be affected by the borderline falls
problem noted above. The disadvantage is that if there are relatively few injurious falls compared
with total falls, it will be hard to tell whether your fall prevention program is making a difference
with respect to injuries. Thus, we recommend that both total and injurious fall rates be computed
and tracked.
The National Database of Nursing Quality Indicators (NDNQI) Data Web site
(https://www.nursingquality.org/data.aspx ) has a link in the bottom right
corner titled ANA is the NQF measure steward. This link takes you to
definitions of falls and patient days so that fall rates may be calculated. A
paraphrase of the March 2012 NDNQI fall definition follows:
A patient fall is an unplanned descent to the floor with or without injury to the
patient. Include falls when a patient lands on a surface where you wouldnt
expect to find a patient. All unassisted and assisted falls are to be included
whether they result from physiological reasons (fainting) or environmental
reasons (slippery floor). Also report patients that roll off a low bed onto a mat
as a fall.
A synopsis of the NDNQI definition for repeat fall follows:
More than one fall in a given month by the same patient after admission to this
unit, may be classified as a repeat fall.
The NDNQI definitions for injury follow:
Nonepatient had no injuries (no signs or symptoms) resulting from

the fall, if an x-ray, CT scan or other post fall evaluation results in a
finding of no injury
Minorresulted in application of a dressing, ice, cleaning of a wound,
limb elevation, topical medication, bruise or abrasion
Moderateresulted in suturing, application of steri-strips/skin glue,
splinting or muscle/joint strain
Majorresulted in surgery, casting, traction, required consultation for
neurological (basilar skull fracture, small subdural hematoma) or
internal injury (rib fracture, small liver laceration) or patients with
coagulopathy who receive blood products as a result of the fall
Deaththe patient died as a result of injuries sustained from the fall
(not from physiologic events causing the fall)
Determine whether staff know the definition of falls and injuries that your
hospital has selected.
5.1.3. What measures do you use for fall rates?

The best measure of falls is one that can be compared over time within a hospital unit to see if
care is improving. Sometimes staff would like to simply track the number of falls that occur
every month or every quarter on a given unit. The problem with only tracking falls is that this
does not account for how full or empty the unit was at any given time. If the unit census is
running low, there will be fewer falls, regardless of the care provided. Therefore, we recommend
that you calculate falls as a rate, specifically, the rate of falls per 1,000 occupied bed days. Later,
we will show you how to make this calculation. You can similarly calculate the rate of injurious
falls per 1,000 occupied bed days.
There is no single right approach to measuring fall rates. Every approach has advantages and
disadvantages. While we make specific recommendations below, the most important point is to
be consistent. Rates calculated by one approach cannot be compared with rates calculated
another way.
Assess whether unit staff understand the difference between number of

falls versus a fall rate.
Define the measurement approach that you will use, and use it
consistently throughout the hospital.
5.1.4. What do you need to calculate fall and fall-related injury rates?
To calculate fall and fall-related injury rates, whether at the unit level or at the overall facility,
you need to know who fell, when the fall occurred, and what the degree of injury was, if any.
You also need to know the daily census on the unit where you would like to calculate the fall
rate, or throughout the hospital if you are calculating a fall rate at the hospital level. To obtain
this information, you must complete two tasks:
1. Generate an incident report for every fall that occurs. The incident report will need to
contain, at a minimum:
The fact that the incident being reported was a fall.

The patient in whom the fall occurred.
The date the fall occurred.
The unit the patient was assigned to at the time of the fall.
The location of the fall.
A detailed report about the circumstances of the fall.
The level of injury, if any.
The circumstances of the fall and level of injury will be important as well for analysis,
discussed later. But for calculation of a fall rate, you need the date the fall occurred and
the responsible unit (if you want to calculate a unit fall rate).
2. Determine whether your hospital information system can provide you with the average
daily census on the unit of interest, or in the hospital, for the time period over which you
want to calculate a fall rate. The average daily census is the number of beds, on average,
that are occupied throughout the day. Because patients come and go quickly on many
hospital units, if you have access to a computerized system to give you the daily census,
this will simplify your life later. 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.
Learn more about your hospitals incident reporting system. Some hospitals
have electronic incident reporting systems that will make it easier to count the
number of falls that have occurred on your unit or in your hospital.
To learn how the National Database of Nursing Quality Indicators (NDNQI)

recommends capturing data on falls and patient-days, refer to the link titled
ANA is the NQF measure steward at the NDNQI Data Web site:
(https://www.nursingquality.org/data.aspx). This will take you to the document
Guidelines for Data Collection on the American Nurses Associations National
Quality Forum Endorsed Measures.
If information technology personnel are developing an electronic incident

reporting system, they may find the Pennsylvania Patient Safety Authoritys
standard structure for incident reporting useful: See section 2.8 (page 60) of
http://patientsafetyauthority.org/PA-PSRS/Documents/part2-
xmldocumentdefinition.pdf.
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
5.1.5. How do you calculate fall rates?

We recommend fall rates be calculated monthly based on the information from incident reports
and daily census discussed above, but quarterly may also be appropriate. The advantage of
monthly data over quarterly is that you have more regular opportunities to feed data back to staff
about their improvements. The disadvantage is that it requires more effort to review data
monthly rather than quarterly.
Lets say, as an example, that you want to calculate the fall rate for the month of April on a 30-
bed unit. Rates are calculated as follows:
First, count the number of falls that occurred during the month of April from your
incident reporting system. Lets say there were three falls during the month of April.
Then figure out, for each day of the month at the same point in time, how many beds
were occupied on the unit. For example, on April 1, there may have been 26 beds
occupied; on April 2, there may have been 28 beds occupied, and so on. The hospital may
have a way of reporting this information to you (for example, midnight census).
Add up the total occupied beds each day, starting from April 1 through April 30. Lets
say the total adds to 879 (out of a maximum of 900, since if all 30 beds were occupied on
all 30 days, 30 x 30 would equal 900). If your hospital can calculate for you the total
number of occupied bed days experienced on your unit during the month of April, then
you can just use this number, skipping step number 2.
Divide the number of falls by the number of occupied bed days for the month of April,
which is 3/879= 0.0034.
Multiply the result you get in #4 by 1,000. So, 0.0034 x 1,000 = 3.4. Thus, your fall rate was 3.4
falls per 1,000 occupied bed days.
Identify a person or team in the organization who will be responsible for

these calculations.
Identify the sources of data that this person or team will use. If current
data are not available or are not accurate, develop a strategy for
improving data quality.
5.1.6. How should you use the monthly data on fall rates?
Use the information on fall rates that you collect in three ways.
First, examine your rates every month and look at the trend over time. How are they changing?
Are they improving or getting worse? Can you relate changes in your fall rate to changes in
practice? 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.
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). Dont overreact to any
individual months data as there can be fluctuations from month to month. Focus on the
underlying trend of the data over time and whether fall rates are increasing or decreasing.
Graphing your data in a run chart is a good way to visually examine trends in the fall rate. A
run chart looks like this:
Falls per 1,000 occupied bed days, by month

8
7
6
5
Falls
4
Median
3
Goal
2
1
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
In this case, the fall rate is plotted on the vertical axis and the month of the year is plotted from
left to right.
A run chart like the one above can be created using a template available at no
cost after free registration at the Institute for Healthcare Improvement Web
site:www.ihi.org/knowledge/Pages/Tools/RunChart.aspx.
The template is a downloadable, easy-to-use spreadsheet that allows you to

enter your data. The spreadsheet also includes a tab with tips for interpreting
your run chart.
When you first implement a quality improvement program and begin tracking performance,
increased fall rates are frequently seen. This is not necessarily related to worse care. Instead, unit
staff members are becoming better at reporting falls that were previously missed. This is another
reason it is equally important to track fall-related injuries at the same time.
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

Surgical: 2.79 falls/1,000 patient days
Stepdown: 3.44 falls/1,000 patient days
Medical-Surgical: 3.92 falls/1,000 patient days
Medical: 4.54 falls/1,000 patient days
Rehabilitation: 7.15 falls/1,000 patient days
For more information, see Lake ET, Shang J, Klaus S, et al. Patient falls:
association with hospital magnet status and nursing unit staffing. Res Nurs
Health 2010;33:413-25.
Further reading for those who want a more indepth look at how to collect and
analyze data on fall rates:
For a general overview of how to collect and use data for quality
improvement: Needham DM, Sinopoli DJ, Dinglas VD, et al. Improving data
quality control in quality improvement projects. Int J Qual Health Care
2009;21(2):145-50.
To learn how to create a basic control chart for falls, see section titled The u-
chart in Mohammed MA, Worthington P, Woodall WH. Plotting basic
control charts: tutorial notes for health care practitioners. Qual Saf Health Care
2008;17:137-45.
To analyze data on rare events, such as injurious falls, learn about the g-type
control chart in Benneyan JC. Number-between g-type statistical quality
control charts for monitoring adverse events. Health Care Manage Sci
2001;4:305-18.
For an overview of how to calculate rates, identify trends, and present data:
Quigley P, Neily J, Watson M, et al. Measuring fall program outcomes. Online
J Issues Nurs 2007;12(2). Available at:
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodic
als/OJIN/TableofContents/Volume122007/No2May07/ArticlePreviousTopic/
MeasuringFallProgramOutcomes.aspx
The second way to use your data on falls is to disseminate the information to key stakeholders
and to unit staff. Post monthly rates in places where all staff can see how the unit is doing. Send
reports to leadership. Dissemination of information on performance is critical to your quality
improvement effort.
The third way to use your data is to study in detail what led to the occurrence of each fall,
particularly falls resulting in injury. Try to understand why the fall occurred and how such an
incident might be prevented in the future. In particular, try to determine whether the falls are
irregular events (e.g., a patients 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.
To get an idea of how incident report data can be used to better understand the
circumstances of falls in a hospital, see this article:
Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls
in a hospital setting: a prospective analysis. J Gen Intern Med 2004;19:732-9.
Root cause analysis is a useful technique for understanding reasons for a failure in the system.
Root cause analysis is a systematic process during which all factors contributing to an adverse
event are studied and ways to improve care are identified. If you are not familiar with root cause
analysis, work with your quality improvement department to learn how to conduct this analysis.
There are two different kinds of root cause analyses: aggregate and individual. For an aggregate
analysis, the Implementation Team would review all falls, or all falls with injury, that occurred
over the previous month, quarter, or year, for example. Using incident report information that is
collected in a standard fashion, the team would seek to determine the main causes of falls in the
hospital or on specific units, and then implement changes to address these causes. Often someone
within the hospitals Quality Management (or similar) department can help in creating reports
that can be reviewed as part of an aggregate root cause analysis.
An individual-level root cause analysis can occur after any fall, particularly falls with injury.
Individual-level root cause analyses are carried out by the Unit Team immediately after a fall.
These analyses can take the form of a postfall safety huddle, which is an informal gathering of
unit staff to discuss what caused the fall and how subsequent falls or injuries can be prevented
(see section 3.4.4 for details).
Sample postfall huddle forms may be found at the Minnesota Hospital
Association Web site:
www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/post-fall-huddle-
revised.pdf
www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/post-fall-huddle-
documentation.pdf
You can use these forms or create your own, based on your hospitals specific
needs. You can also build a form based on the postfall assessment form for root
cause analysis (Tool 3O) in this toolkit. The key is to do a thorough assessment,
identify the causes contributing to the fall, and come to a decision about actions
that need to be taken to prevent a fall or injury in the future. Data should be
collected in a standardized fashion, which should include all the data needed to
complete an incident report. Standard data structures for incident reports may
be found in the resource box in section 5.1.4.
A primer on root cause analysis is available on the AHRQ Patient Safety
Network Web site at: http://psnet.ahrq.gov/primer.aspx?primerID=10.
For additional information and tools about root cause analysis, see the Veterans
Affairs National Center for Patient Safety Web site at:
www.patientsafety.gov/vision.html#rca.
For tools, see: www.patientsafety.gov/CogAids/RCA/index.html#page=page-1.
For a step-by-step guide to aggregate root cause analysis: see Neily J, Ogrinc G,
Mills P, et al. Using aggregate root cause analysis to improve patient safety. Jt
Comm J Qual Patient Saf 2003;29(8):434-9.
Identify audiences for the data at different levels of the organization and
determine through which paths you will provide the data. For example,
for senior managers, report the data in a leadership meeting or
performance improvement committee meeting.
Assess whether unit staff know the units fall and fall-related injury rate
and whether it is improving over time.
5.1.7. Are there national benchmarks you can use for comparison with your fall
rates?
The question of how well your hospital is performing relative to other hospitals often arises.
Unfortunately, there are no national benchmarks with which you can compare your performance.
In part this is due to the difficulties in making sure patients are similar across hospitals, since
some patients are more likely to fall than others and hospitals care for different types of patients.
Therefore, we encourage you to focus more on improvement over time within your units and
your hospital overall, rather than focusing strictly on your hospitals performance compared with
an external benchmark.
That having been said, there are a number of ongoing initiatives to determine fall rates using a
standardized method across a large number of hospitals. These include the National Database of
Nursing Quality Indicators, the Collaborative Alliance for Nursing Outcomes, and the Centers
for Medicare & Medicaid Services (CMS) reporting on falls with trauma occurring in hospitals.
Learn more about ongoing data collection initiatives:
National Database of Nursing Quality Indicators, Data:

https://www.nursingquality.org/data.aspx.
Collaborative Alliance for Nursing Outcomes, CALNOC Registry:
www.calnoc.org/displaycommon.cfm?an=1&subarticlenbr=8.
For more information on the public reporting of falls with trauma that
occur in hospitals participating in the Medicare program, go to the U.S.
Department of Health and Human Services Hospital Compare Web site
(www.hospitalcompare.hhs.gov/Data/RCD/Hospital-Acquired-
Conditions.aspx ) and look for the link to the Hospital Acquired
Conditions measures. The actual rates of falls with trauma occurring
within the hospital may be found on the Medicare data Web site (use
filter to restrict reported measures to Falls and injuries):
https://data.medicare.gov/dataset/Hospital-Acquired-Condition-
Measures/qd2y-qcgs.
5.1.8. How can you improve the quality of the data being collected for fall rates?
To improve data quality, you will need to improve staff reporting of falls, particularly the
circumstances surrounding the fall (see Tool 3O, Postfall assessment for root cause analysis).
Often, critical details are left out in the reporting of falls and there are only limited opportunities
to learn what makes for a good incident report. Therefore, consider reviewing completed incident
reports with staff on a monthly basis.
Check on the quality of the incident reports being filled out at your hospital or
on your unit using Tool 5A, Information To Include in Incident Reports.
5.2. How do you measure fall prevention practices?

5.2.1. Why measure fall prevention practices?
While measuring fall rates is the ultimate test of how your facility or unit is performing, fall rates
are limited in that they do not tell you how to improve care. If your fall rate is high, on what
specific areas should you focus? To know where to focus improvement efforts, it is important to
measure whether key practices to reduce falls are actually happening.
Many important practices could be measured in assessing fall prevention. We recommend
initially looking at no more than two, such as:
Performance of fall risk factor assessment within 24 hours of admission.

Performance of care planning that addresses each risk factor identified during fall risk
factor assessment.
5.2.2. How do you review performance of a fall risk factor assessment within 24
hours of admission?
As the first step in prevention, it is essential to ensure that a fall risk factor assessment is
performed within 24 hours of admission. The risk factor assessment could either be a standard
scale such as the Morse Fall Scale (Tool 3H) or STRATIFY (Tool 3G), or it could be a checklist
of risk factors for falls in the hospital.
The key question is not so much whether a scale was used, but rather whether the known risk
factors for falls were assessed. In some cases, the risk factors will vary depending on the hospital
unit, so the risk factor assessment may need to be tailored to the unit. Determine whether this fall
risk factor assessment is being performed.
Sample Protocol for Assessing Performance of Fall Risk Factor Assessment
Take a sample of records of patients newly admitted to your unit within the past month. For
an informal audit, an arbitrary number such as 10 or 20 records may be sufficient for initial
assessments of performance. A more formal audit might review 10 percent of all patients
admitted to the unit.
Identify medical and nursing notes from the first 24 hours of hospitalization. These should
include the admission nursing assessment, physicians admission note, and subsequent
nursing progress notes.
Determine whether there is any documentation of a fall risk factor assessment. This might
include mention of the patients level of orientation and cognition, gait and balance,
continence status, and number and types of prescribed medications, as well as number of
diagnoses.
Determine whether key findings from the fall risk factor assessment were further explored.
For example, if a patient is noted to be disoriented, is there an assessment for delirium (see
Tool 3L)?
Calculate the percentage of patients having any documentation of a fall risk factor
assessment as well as the percentage of cases in which key findings from the fall risk factor
assessment were further explored.
5.2.3. How do you assess care planning to ensure that it addresses each deficit
on the fall risk factor assessment?
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. This
requires critical thinking on the part of staff and a tailored approach to each patient based on the
individual patients risk factors. Ensure that the care plans address all areas of risk.
Sample Assessment of Care Planning Performance
1. Take a sample of records of patients newly admitted to your unit within the past month who
were found to have risk factors for falls. Ten or 20 records may be sufficient for initial
assessments of performance.
2. For each patient, determine the patients identified risk factors.
3. Identify the fall prevention components of care plans prepared shortly after admission.
4. Determine whether each patients unique fall risk factors are addressed in the care plans.
5. Calculate the percentage of the assessment patients known fall risk factors that are addressed
in the care plan.
6. Repeat steps 1-5 for a sample of patients whose fall risk factors changed during the hospital
stay. Determine whether the care plan was updated when risk factors changed.
Find detailed instructions on how to perform a review of medical records at the

Duke University Medical Center Patient Safety/Quality Improvement Web site:
http://patientsafetyed.duhs.duke.edu/module_b/module_overview.html.
5.2.4. What data sources should be used in measuring fall prevention practices?
In measuring key practices, data used in calculating performance rates can be obtained from a
number of sources. These include direct observations of care, surveys of staff, and medical
record reviews. Each approach has its strengths and limitations:
Direct observation of care, where a trained observer determines, for example, whether a
patients call light is within reach, will be the most accurate approach for certain care
processes but can be time consuming.
Surveys may be helpful in certain circumstances but rely on staff members recall of
specific events, and these recollections might be inaccurate.
Medical record reviews are the easiest approach to complete but rely on what is
documented in the record, and much care for fall prevention may not be documented.
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.
Use this tool adapted from the Royal College of Physicians FallSafe program
for auditing key processes of care (Tool 5B, Assessing Fall Prevention Care
Processes).
5.2.5. What should be done if you are not doing well on your measures of fall
prevention practices?
Good performance on these key processes of care is critical to preventing falls. If you are not
doing well, or as well as you would like, in one of these key areas, it provides an opportunity for
improvement. Examine what the problem is and plan how to overcome this barrier. For example,
are staff engaged in the program? Do they know what they need to do? Go back to section 2.2 for
suggestions on how to make needed changes.
5.3. Checklist for measuring progress

The checklist for measuring progress can be found in Tools and Resources
(Tool 5C, Measuring Progress Checklist).
6. How do you sustain an effective fall
prevention program?
The only step more difficult than implementing practice
change is ensuring that those changes become woven into
the day-to-day fabric of operations so that they are
sustained beyond the initial formal improvement effort or
special campaign. It is sometimes easy to adopt new
practices in response to an immediate need, such as an
impending Joint Commission visit, and considerably more
difficult to maintain those practices over time. To sustain
improvement, changes need to become so integrated into
existing organizational structures and routines that they are
no longer noticed as separate from business as usual.
While sustaining changes logically follows initial

improvements, it is important to begin thinking early in the
improvement process about what will be needed to make
lasting change. Throughout the implementation process,
you should consider questions such as:
Who will be responsible for sustaining active fall

prevention efforts on an ongoing basis?
How will you continue to monitor fall rates and fall prevention care processes?
What types of ongoing organizational support do you need to keep the new practices in
place?
How can you reinforce the desired results?
Sustaining Redesigned Prevention Practices: Locally Relevant

Considerations
Your hospital may find sustaining redesigned practices challenging for reasons
such as these:
Fall prevention may be viewed as a time-limited initiative rather than an

ongoing program.
Change specific to fall prevention has not been incorporated into routine
behavior.
More unit-based champions are needed.
Staff need to take ownership of fall prevention.
Mechanisms are needed to provide feedback to staff on the
effectiveness of fall prevention strategies and to celebrate success.
This section will provide suggestions to address these types of challenges.
Section 6: Sustain 81
6.1. Who will be responsible for sustaining active fall prevention efforts on an
ongoing basis?
Sustaining efforts at fall prevention within your hospital requires responsibility for the hospitals
fall prevention program to be clearly assigned (see section 2). A key decision for your
organization will be in what form to keep the Implementation Team going. If you have a
standing fall prevention committee and it functioned as the Implementation Team, the fall
prevention committee can continue to oversee the program. If the Implementation Team was
chartered on a time-limited basis and there is no fall prevention committee to hand off to, a
subset of Implementation Team members could form the core of a new standing fall prevention
committee. The key message is that a successful fall prevention program needs to be an ongoing
effort, and oversight cannot end after initial implementation is complete.
For ease of presentation in the rest of this section, we will refer to the group responsible for fall
prevention going forward as the Sustainability Team, whether it is the original Implementation
Team or a different group. The Sustainability Team will serve as a key dissemination point for
new information (e.g., team education sessions with invited speakers) and will take up new
challenges (e.g., revise online documentation forms).
The Sustainability Team will ensure that data collection and regular reporting of fall rates occur
and are fully integrated into routine work processes. Regular meetings will be important in
discussing outcomes and updating materials and policies on an ongoing basis.
An important element for keeping the Sustainability Team going is to allow a variety of levels of
participation in team activities. There may be a core group of individuals who meet on a monthly
basis to review fall data and others who need only attend meetings on an as needed basis. This
approach allows people to participate in a way that is respectful of their time and helps to
maintain a positive dynamic at team meetings.
6.2. How will you continue to monitor fall rates and fall prevention care
processes?
Continuing to monitor fall rates and fall prevention care processes is critical for the sustainability
of a fall prevention program. (Details on how to measure fall rates and fall prevention care
processes are provided in section 5. Information on the Plan, Do, Study, Act approach to
continuous improvement is provided in section 2.2.1.) Measurement is necessary for
improvement, particularly as a check to ensure the program is not veering off track.
Measurement is also needed to show ongoing success of the program to leadership. Leaders will
be more willing to invest in a program that has credible evidence of success.
To regularly measure fall rates requires setting up a routine workflow (a scheduled set of
activities and tasks performed by designated people) for data collection. You will need to decide
who will calculate fall rates from incident reports and who will audit fall-related care processes
to ensure these occur as they should. You also will need to decide to whom these data will be
reported and what will be done with the data. For example, how soon prior to each meeting of
the Sustainability Team will the data need to be sent for review?
In addition, the Sustainability Team will need to discuss what change in fall rates represents a
real success (or concern) for the hospital, versus fluctuations in the data that can be explained by
other changes, to avoid inappropriately reacting to noise in the data. For example, more patients
with fall risk factors might be admitted during the flu season, so the fall rate might go up during
that time. Or the hospital may have migrated to a new incident reporting system, which improved
staff adherence to reporting falls, thereby making the fall rate higher.
6.3. What types of ongoing organizational support do you need to keep the new
practices in place?
While the frontline work to prevent falls depends on unit staff, the Sustainability Team will need
support from other parts of the organization to be successful. Support for the Sustainability Team
can include activities such as:
Training for new employees and refresher training for current employees;
Prompt filling of staff vacancies by human resources;
Prompt provision of needed supplies and equipment by facility management; and
Help from information technology staff to assist with regularly reporting data.
If your organization is using Unit Champions, the Sustainability Team will need to consider
strategies to keep them engaged and a method to replace Unit Champions when the original
champions change responsibilities or positions. Similarly, if you do not have Unit Champions
but multiple staff who serve as fall prevention resource staff on the units, you will need
processes for keeping them engaged and replacing them when needed.
Communication is essential to keep staff involved and up to date. The Sustainability Team
therefore will need to consider how to engage and communicate with the staff at large as new
practices become integrated into ongoing operations. Consider ongoing information briefs in
your staff bulletin. Posters can also be used; rotating them every few weeks may be important in
keeping staff engaged. Make fall prevention a standard part of yearly staff education fairs or
other similar events.
Integrating the Sustainability Team into the existing hospital organization will help ensure it can
continue its mission. To further solidify ongoing support, you should determine to which
oversight committee the Sustainability Team will report in the larger organizational structure.
The most appropriate committee will depend on the structure of your organization. In some
places it may be the Patient Safety Committee, in others the Quality Council.
Communication with the oversight committee should include not only updates on patient
outcomes (e.g., fall rates), but also the financial implications of maintaining the fall prevention
program (e.g., in terms of hospitalwide cost savings due to fewer falls, after program costs are
accounted for). Reviewing the business case (see Tool 1D) for fall prevention with leadership
may be helpful, especially in cases of leadership turnover.
In addition to assessing changes in processes and outcomes of care, the Sustainability Team will
need to examine the extent to which organizational structures and routines have changed in
response to the fall prevention program. Without such change, it is possible that only short-term
gains will be accomplished. Examples of items that might be assessed are described below.
Examples of assessment items for structures and routines that support fall
prevention:
Are unit staff very familiar with their role in preventing falls and how
their role relates to other staff members?
Are there unit experts who can be given extra training and work within
units to maintain fall prevention awareness and knowledge?
Are there systems and prompts in place to ensure that care is carried out
appropriately? For example, does the electronic health record have a
section on assessment and management of fall risk factors?
Have barriers to obtaining needed supplies and equipment, such as
assistive devices, been addressed?
Is performance routinely tracked?
Are performance data regularly reported to staff?
Is there a committee that monitors fall rates and care processes and
ensures that needed resources are available to prevent falls?
Is hospital leadership engaged in the process of sustaining the fall
prevention program (e.g., by being invited to visit units to view ongoing
fall prevention activities or by meeting with the committee that oversees
fall prevention)?
Key elements for a thriving Sustainability Team are summarized in Tools and
Resources (Tool 6A, Sustainability Tool).
6.4. How can you reinforce the desired results?

Generating and maintaining excitement about change is critical to success. Given the
obstacles to implementation, improvements in performance measures may not initially be
evident. Even with good implementation, fall rates may appear to trend upward initially due to
better reporting. It is thus important to find small successes early on that can be rewarded.
Another barrier to sustainability is staff turnover. To address this barrier, ensure that
orientation for new clinical staff is modified to include a focus on fall prevention and that new
staff are appropriately integrated into their units fall prevention program. This will help to
maintain a unit culture that is positively oriented toward fall prevention.
This article describes strategies to reinforce desired outcomes:
Weinberg J, Proske D, Szerszen A. An inpatient fall prevention initiative in a

tertiary care hospital. Jt Comm J Qual Pat Saf 2011;37(7):317-25.
Key points from this article include:
Importance of continued leadership support and staff dedication at all

levels.
Ongoing monitoring and measuring of fall rates.
Ongoing monthly fall meetings attended by the hospital fall committee

cochairs, managers, and clinical staff to address root causes of falls.
To reinforce desired results, you also need to be aware of obstacles to sustaining your fall
prevention program. For example:
Old habits have a way of resurfacing. People may slowly go back to old approaches. This
tendency supports the need for ongoing refresher training in the context of each units
needs.
Practices that had become accepted may suddenly be more difficult to perform or the
availability of needed resources may change. Such unintended consequences of quality
improvement are well recognized. For example, budget cuts may limit the number of
sitters/safety attendants available to monitor very high risk patients for falls.
One Hospitals Mobility Program: An Application of Toolkit Concepts
To show how this toolkit can apply in real life, we have provided a real example of one
hospitals attempt to improve its care. We chose an example of a mobility program, because
mobility programs have been shown to decrease hospital length of stay and costs and to increase
the likelihood that a patient is discharged home rather than to a nursing home or rehabilitation
facility. The hospital (an academic medical center) was concerned about patients decline in
mobility during inpatient stays, a factor that puts patients at risk for falls, but did not have
enough physical therapy staff to provide sufficient mobility training. We outline the hospitals
change process below.
1. Readiness for change: Although senior leadership and medical staff had several discussions
about the importance of maintaining patient mobility, the hospital lacked a strong
promobility culture.
One particular clinical event helped create urgency for implementing a mobility program. A
transporter had difficulty transferring one patient into his car and the patient was concerned
about how he would get out of the car when he got home. This was a wake-up call to staff
because they realized the patient had not been out of bed since admission but needed to be
able to get out of his car and into his home on his own after discharge. However, the mobility
program did not begin until a newly hired individual within the Nursing Department was
tasked with implementing the change. This new individual was committed to the programs
goals and was able to pull together the right team to initiate the mobility program.
2. Best practices and planned implementation: The mobility program was based on the
principle that bed rest should not be the default for patients and uses a nurse-driven plan of
care. As long as a physician has not set the patient to restricted mobility, the nurse follows
the default electronic order set and progressively moves the patient through a mobility scale
from 1 (turn patient) to 6 (ambulation with assist as needed). Nurses and patient care
technicians take primary responsibility for patient mobility, with physical therapy or medical
staff directing the mobility plan if there is a skilled need and/or weight-bearing limitations.
3. Implementation: The implementation efforts were led by an interdisciplinary team that

included physical therapy, nursing, and medical staff. The team implemented the program in
two pilot units (medical intensive care and trauma/orthopedics), followed by a hospitalwide
launch. Initial education included general computer training on the order set and a 2-hour
nurse training on how to achieve each level of the mobility scale. Super-users on the pilot
units helped train the other units.
The units use a status board to present key patient information, including the mobility score,
and physicians can quickly see and check where patients are on the scale. Physicians also use
interactions with patients as a training opportunity. When at the bedside with residents and
nurses, one physician often talks to patients about their mobility score and encourages them
to progress. The implementation of the mobility program had positive benefits in creating
more opportunities for discussion about patient mobility between physicians, nurses, and
patients.
The team experienced some barriers to implementation. It was difficult for some staff to
change from assuming patients should be on bed rest to encouraging progressive increases in
mobility. Nursing staff remembered previous experiences with patients falling and worried
that fall rates would increase with increased ambulation. To reduce this fear, the team
connected staff with nurses on successful units to share strategies for successful
implementation.
4. Monitoring change: Measuring processes and outcomes is one of the implementation teams
next steps. Although objective data have not been collected yet, the team reports that many
units have successfully adopted a promobility culture and more patients are standing or
sitting in a chair than before.
5. Sustaining the program: The implementation team recently faced some challenges in
sustaining the program after moving to a new facility. The new facility has patient handling
equipment to help staff move patients, which has introduced new questions about the
mobility scale. The team has had to retrain staff to emphasize that moving a patient into a
chair using a lift does not mean that the patient has progressed from reclining in bed
(mobility 2) to getting to chair on own (mobility 5).
Strategies the implementation team could use to reinforce the desired results of the mobility
program include:
Demonstrating reductions in the risk of falls and improved independence at discharge.

Having unit champions reinforce discussions about mobility as part of the care plan on
each patient, at interdisciplinary rounds and case conferences.
Providing continuing education sessions that emphasize mobility.
Hosting an annual mobility day at the hospital.
These efforts would highlight the priority of mobility at various levels of the organization and
would help create a culture throughout the institution of maintaining mobility.
6.5. Summary
Significant time and effort have gone into getting your hospital to this point. By now, you have
been successful at changing how things get done and in implementing best practices for fall
prevention. You have systems in place to ensure that these best practices become the standard
way care is now provided. Because of these changes, you can now demonstrate how your
patients have better outcomes with fewer falls. These are major achievements for the
Implementation Team and the hospital, and everyone should be congratulated for this collective
effort.
Finally, always remember that no matter how well you are doing, sustained attention is still
needed to keep improvements on track. Perfection in fall prevention is never achieved. There are
always additional steps to get closer to the ideal of a fall-free hospital.
7. Tools and Resources
Section 7: Tools 89
Section 7 Table of Contents
Tools and Resources Page
A Introduction and Overview for Stakeholders 92
1A Hospital Survey on Patient Safety Culture 94
1B Stakeholder Analysis 100
1C Leadership Support Assessment 102
1D Business Case Form 103
1E Resource Needs Assessment 105
1F Organizational Readiness Checklist 106
2A Interdisciplinary Team 107
2B Quality Improvement Process 113
2C Current Process Analysis 115
2D Assessing Current Fall Prevention Policies and Practices 118
2E Fall Knowledge Test 121
2F Action Plan 125
2G - Managing Change Checklist 129
3A Master Clinical Pathway for Inpatient Falls 130
3B Scheduled Rounding Protocol 132
3C Tool Covering Environmental Safety at the Bedside 133
3D Hazard Report Form 135
3E Clinical Pathway for Safe Patient Handling 137
3F Orthostatic Vital Sign Measurement 138
3G STRATIFY Scale for Identifying Fall Risk Factors 139
3H Morse Fall Scale for Identifying Fall Risk Factors 141
3I Medication Fall Risk Scale and Evaluation Tools 143
3J Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status 153
Questionnaire, and Confusion Assessment Method
3K Algorithm for Mobilizing Patients 158
3L Patient and Family Education 148
3M Sample Care Plan 150
3N Postfall Assessment, Clinical Review 160
3O Postfall Assessment for Root Cause Analysis 163
3P Best Practices Checklist 170
4A Assigning Responsibilities for Using Best Practices 171
4B Staff Roles 172
4C Assessing Staff Education and Training 174
4D Implementing Best Practices Checklist 176
5A Information To Include in Incident Reports 177
5B Assessing Fall Prevention Care Processes 179
5C Measuring Progress Checklist 182
6A Sustainability Tool 183
Section 7: Tools 90
A: Introduction and Overview for Stakeholders
Background: This template can serve as a letter to key players in the hospital to introduce them
to the goals and purpose of a fall prevention program.
Reference: Developed by Falls Toolkit Research Team.
How to use this tool: Adapt this letter as needed and present it to senior leaders to enlist their
support before mounting your fall prevention program. You may want to use Tool 1B,
Stakeholder Analysis, to identify individuals and departments who may have an interest in the
program.
Dear <Name>:
We would like to introduce you to our fall prevention program. We hope that you will support
this exciting new endeavor.
What is this program? <Hospital name> is embarking on an important new initiative focused
on the prevention of falls among our acute care patients.
Why is this program important? Falls with serious injury occurring during acute care stays
represent a significant threat to patient safety, and increase the length of inpatient stays by 6.9
days and hospital charges by$13,806.i In addition, falls with serious trauma have become a
never event from the standpoint of Medicare reimbursement. Thus, falls represent both a
patient safety priority and an economic priority for health care organizations. Fall rates are as
high as <xxx falls per 1,000 bed days of care> on some of our units.
How might this program affect me/my area? In the past, fall prevention has sometimes been
seen as solely a nursing unit responsibility. However, recent research makes it clear that
successfully reducing fall incidence requires a coordinated interdisciplinary approach. Thus, the
implementation of new prevention approaches may require, for example, the efforts of:
Materials management: Do we have the most evidence-based products and equipment

needed to prevent falls? Are new products, such as hospital beds, evaluated with this
outcome in mind?
Environmental services: Are environmental hazards in the hospital (e.g., spills, electrical
cords) appropriately managed?
Information technology: Is information about fall prevention interventions effectively
integrated into the electronic health record?
Pharmacy: Has the hospital formulary been reviewed to see if certain medicines (e.g.,
sleep aids) should be restricted in patients at risk for falls?
Physicians: Are patients medications checked for their risk of causing falls? Is the
patients mental status formally tested where appropriate?
i
Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern hospitals.
Jt Comm J Qual Patient Saf 2011;37(2):81-7.
Section 7: Tools 91
Rehabilitation services: Are protocols in place for ordering physical and occupational
therapy? Are needed assistive devices (e.g., walkers, wheelchairs) available at the
bedside? Are appropriate orders on file for patients activity levels?
Quality improvement: Are quality improvement specialists available to assist the team
working on this effort?
Transport: Are patients who are at high risk for falls supervised when taken off the unit
for diagnostic or therapeutic activities?
What will happen? For this program, we will use the U.S. Agency for Healthcare Research and
Qualitys new toolkit. This comprehensive toolkit outlines steps in the improvement process and
provides relevant tools. Using these tools, we will assess staff awareness and knowledge of fall
prevention, analyze patient care processes to identify opportunities for improvement, and target
interventions in those areas. Fall incidence while patients are under our care will be analyzed
more closely so that progress can be assessed.
Everyone has a role: Most important in this effort is a shift of thinking and culture, from
regarding falls as inevitable to seeing them as events that can be reduced through a
comprehensive program. Your support in helping <hospital name> staff make this shift is
essential to the success of this effort. Thank you.
Section 7: Tools 92
1A: Hospital Survey on Patient Safety Culture
Background: The Hospital Survey on Patient Safety Culture is a staff survey designed to
help hospitals assess the culture of safety in their institutions. Since 2004, hundreds of
hospitals have implemented the survey.
There is a growing recognition that organizational change to improve patient safety, including
fall prevention, requires a general culture of safety among its staff. Achieving a culture of
safety requires an understanding of the values, beliefs, and norms about what is important in
an organization and what patient safety attitudes and behaviors are expected and appropriate.
This requires a culture that views errors as opportunities to improve the system, not the result
of individual failure. For example, it may be difficult for your hospital to overcome chronic
underreporting of falls if you have a culture where acknowledgment of error is not acceptable.
Reference: Available on the AHRQ Web site:

www.ahrq.gov/qual/patientsafetyculture/hospscanform.pdf
How to use this tool: Consider administering a survey to assess the culture of safety in your
hospital. The AHRQ Hospital Survey on Patient Safety Culture examines patient safety
culture from a hospital staff perspective. The survey can be completed by all interdisciplinary
team members and staff on units preparing to implement the fall prevention program but is
best suited for:
Hospital staff who have direct contact or interaction with patients;

Hospital staff who may not have direct contact or interaction with patients but whose
work directly affects patient care;
Hospital-employed physicians who spend most of their work hours in the hospital; and
Hospital supervisors, managers, and administrators.
A users guide that provides information on getting started, selecting a sample, determining
data collection methods, establishing data collection procedures, conducting a Web-based
survey, preparing and analyzing data, and producing reports may be found at
www.ahrq.gov/qual/patientsafetyculture/hospcult.pdf.
The results of this survey can provide a hospital with an understanding of the safety-related
perceptions and attitudes of its managers and staff. Results can be compared with those of
other hospitals using the Hospital Survey on Patient Safety Culture Comparative Database
available at: www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm.
Section 7: Tools 93
Hospital Survey on Patient Safety
Instructions
This survey asks for your opinions about patient safety issues, medical error, and event reporting in your hospital and will
take about 10 to 15 minutes to complete.
If you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.
An event is defined as any type of error, mistake, incident, accident, or deviation,

regardless of whether or not it results in patient harm.
Patient safety is defined as the avoidance and prevention of patient injuries or adverse
events resulting from the processes of health care delivery.
SECTION A: Your Work Area/Unit

In this survey, think of your unit as the work area, department, or clinical area of the hospital where you spend most of your
work time or provide most of your clinical services.
What is your primary work area or unit in this hospital? Select ONE answer.
a. Many different hospital units/No specific unit h. Psychiatry/mental health
b. Medicine (non-surgical) i. Rehabilitation
c. Surgery j. Pharmacy
d. Obstetrics k. Laboratory
e. Pediatrics l. Radiology
f. Emergency department m. Anesthesiology
g. Intensive care unit (any type) n. Other, please specify:
Please indicate your agreement or disagreement with the following statements about your work area/unit.
Strongly Strongly
Disagree Disagree Neither Agree Agree
Think about your hospital work area/unit
1. People support one another in this unit ................................................................. 1 2 3 4 5

2. We have enough staff to handle the workload ...................................................... 1 2 3 4 5
3. When a lot of work needs to be done quickly, we work together as a team to
get the work done .................................................................................................. 1 2 3 4 5
4. In this unit, people treat each other with respect ................................................... 1 2 3 4 5
5. Staff in this unit work longer hours than is best for patient care ........................... 1 2 3 4 5
Section 7: Tools 94
SECTION A: Your Work Area/Unit (continued)
Strongly Strongly
6. We are actively doing things to improve patient safety ........................................ 1 2 3 4 5

7. We use more agency/temporary staff than is best for patient care ........................ 1 2 3 4 5
8. Staff feel like their mistakes are held against them ............................................... 1 2 3 4 5
9. Mistakes have led to positive changes here............................................................. 1 2 3 4 5
10. It is just by chance that more serious mistakes dont happen around here ..............
1 2 3 4 5
11. When one area in this unit gets really busy, others help out ................................... 1 2 3 4 5
12. When an event is reported, it feels like the person is being written up, not the
problem ................................................................................................................... 1 2 3 4 5
13. After we make changes to improve patient safety, we evaluate their
effectiveness .......................................................................................................... 1 2 3 4 5
14. We work in crisis mode trying to do too much, too quickly .............................. 1 2 3 4 5
15. Patient safety is never sacrificed to get more work done ...................................... 1 2 3 4 5
16. Staff worry that mistakes they make are kept in their personnel file .................... 1 2 3 4 5
17. We have patient safety problems in this unit ........................................................ 1 2 3 4 5
18. Our procedures and systems are good at preventing errors from happening.........
1 2 3 4 5
SECTION B: Your Supervisor/Manager
Please indicate your agreement or disagreement with the following statements about your immediate supervisor/manager or
person to whom you directly report.
Strongly Strongly

1. My supervisor/manager says a good word when he/she sees a job done
according to established patient safety procedures ............................................... 1 2 3 4 5
2. My supervisor/manager seriously considers staff suggestions for improving
patient safety ......................................................................................................... 1 2 3 4 5
3. Whenever pressure builds up, my supervisor/manager wants us to work
faster, even if it means taking shortcuts ................................................................ 1 2 3 4 5
4. My supervisor/manager overlooks patient safety problems that happen over
and over ................................................................................................................. 1 2 3 4 5
Section 7: Tools 95
SECTION C: Communications
How often do the following things happen in your work area/unit?
Some- Most of
Never Rarely times the time Always
1. We are given feedback about changes put into place based on event reports .......
1 2 3 4 5
2. Staff will freely speak up if they see something that may negatively affect
patient care ............................................................................................................ 1 2 3 4 5
3. We are informed about errors that happen in this unit .......................................... 1 2 3 4 5
4. Staff feel free to question the decisions or actions of those with more
authority ................................................................................................................ 1 2 3 4 5
5. In this unit, we discuss ways to prevent errors from happening again .................... 1 2 3 4 5
6. Staff are afraid to ask questions when something does not seem right ................. 1 2 3 4 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes happen, how often are they reported?
Some- Most of
Never Rarely times the time Always

1. When a mistake is made, but is caught and corrected before affecting the
patient, how often is this reported? ....................................................................... 1 2 3 4 5
2. When a mistake is made, but has no potential to harm the patient, how often
is this reported? ....................................................................................................... 1 2 3 4 5
3. When a mistake is made that could harm the patient, but does not, how often
is this reported? ....................................................................................................... 1 2 3 4 5
SECTION E: Patient Safety Grade

Please give your work area/unit in this hospital an overall grade on patient safety.

A B C D E
Excellent Very Good Acceptable Poor Failing
SECTION F: Your Hospital

Please indicate your agreement or disagreement with the following statements about your hospital.
Strongly Strongly
Think about your hospital
1. Hospital management provides a work climate that promotes patient safety........
1 2 3 4 5
2. Hospital units do not coordinate well with each other .......................................... 1 2 3 4 5
3. Things fall between the cracks when transferring patients from one unit to
another .................................................................................................................... 1 2 3 4 5
4. There is good cooperation among hospital units that need to work together ........ 1 2 3 4 5
Section 7: Tools 96
SECTION F: Your Hospital (continued)
Strongly Strongly
Think about your hospital
5. Important patient care information is often lost during shift changes ................... 1 2 3 4 5
6. It is often unpleasant to work with staff from other hospital units ........................ 1 2 3 4 5
7. Problems often occur in the exchange of information across hospital units .........
1 2 3 4 5
8. The actions of hospital management show that patient safety is a top priority .....
1 2 3 4 5
9. Hospital management seems interested in patient safety only after an adverse
event happens ........................................................................................................ 1 2 3 4 5
10. Hospital units work well together to provide the best care for patients ................
1 2 3 4 5
11. Shift changes are problematic for patients in this hospital ..................................... 1 2 3 4 5
SECTION G: Number of Events Reported

In the past 12 months, how many event reports have you filled out and submitted?
a. No event reports d. 6 to 10 event reports

b. 1 to 2 event reports e. 11 to 20 event reports
c. 3 to 5 event reports f. 21 event reports or more
SECTION H: Background Information

This information will help in the analysis of the survey results.
1. How long have you worked in this hospital?
a. Less than 1 year d. 11 to 15 years

b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
2. How long have you worked in your current hospital work area/unit?

3. Typically, how many hours per week do you work in this hospital?
a. Less than 20 hours per week d. 60 to 79 hours per week
b. 20 to 39 hours per week e. 80 to 99 hours per week
c. 40 to 59 hours per week f. 100 hours per week or more
Section 7: Tools 97
SECTION H: Background Information (continued)
4. What is your staff position in this hospital? Select ONE answer that best describes your staff position.
a. Registered Nurse j. Respiratory Therapist
b. Physician Assistant/Nurse Practitioner k. Physical, Occupational, or Speech Therapist
c. LVN/LPN l. Technician (e.g., EKG, Lab, Radiology)
d. Patient Care Asst/Hospital Aide/Care Partner m. Administration/Management
e. Attending/Staff Physician n. Other, please specify:
f. Resident Physician/Physician in Training
g. Pharmacist
h. Dietician
i. Unit Assistant/Clerk/Secretary
5. In your staff position, do you typically have direct interaction or contact with patients?
a. YES, I typically have direct interaction or contact with patients.

b. NO, I typically do NOT have direct interaction or contact with patients.
6. How long have you worked in your current specialty or profession?
SECTION I: Your Comments

Please feel free to write any comments about patient safety, error, or event reporting in your hospital.
THANK YOU FOR COMPLETING THIS SURVEY.
Section 7: Tools 98
1B: Stakeholder Analysis
Background: The purpose of stakeholder analysis is to help program initiators identify which departments and individuals will have
an interest in the program, where barriers might exist, and what actions need to be taken to obtain the buy-in and participation of those
departments and individuals.
Reference: This tool was adapted from a template developed by Project Agency, a company focused on effective project
management, and is available at: http://projectagency.co.uk/documents/b316stakeholderform.pdf.
How to use this tool: Complete the form with information regarding all the individuals you consider key stakeholders. You may need
to set up a meeting with them to obtain their answers. Examples: information technology officer, director of supply/materials,
housekeeping director, quality improvement (QI) department, therapy departments, diagnostic departments, emergency department.
This form should be completed by the individual interested in initiating or reinvigorating a fall prevention program.
Use the completed template to identify actions needed to involve all stakeholders in the program. Ensure that all identified needs have
been met before proceeding with the QI initiative. For example, the program may need process assistance from the QI department.
Since this program may be competing with other QI priorities, it may be important to determine who shapes the QI agenda and how to
get this program prioritized at a higher level. An example is shown in the form below. A blank form follows.
What the program

Interest or requirement needs from Perceived attitudes
Stakeholder in the program stakeholder and risks Actions to take
Example: health Gatekeeper for making The program may need May not want to make Seek information about
information systems any changes to the to add or make changes changes until other the process for
officer electronic health record to any parts of the EHR changes are also in requesting/making these
(EHR) system. Not that concern fall risk process, or other kinds of changes and how
necessarily interested in assessment, preventive changes may already be this person relates in the
the program beyond his measures, and postfall in process. overall organizational
general mandate to keep care. structure to program
the EHR tied to clinical leaders/advocates.
documentation needs.
Section 7: Tools 99
What the program
Interest or requirement needs from Perceived attitudes
Stakeholder in the program stakeholder and risks Actions to take
Section 7: Tools 100

1C: Leadership Support Assessment
Background: This tool can be used to assess senior leadership support for implementing a fall
prevention program. For more information on who is part of the senior leadership team, see the
resource box in section 1.3 of the toolkit text.
Reference: Developed by Falls Toolkit Research Team based on the Ontario Agency for Health
Protection and Promotions Facility-Level Situation Assessment:
www.oahpp.ca/services/documents/jcyh/jcyh-for-hosptials/tools-for-implementation/facility-
level-situation-assessment.pdf.
How to use this tool: Complete the checklist. This assessment is best suited for hospital
supervisors, managers, and administrators.
Review the responses to ascertain the level of leadership support. If the response to several of
these items is no, it could threaten the success of your improvement process. Analyze the areas
where support is not evident and take steps to inform leadership about the urgency to change.
Leadership Support Assessment

Yes No
Patient safety is clearly articulated in the organizations strategic plan.
Someone in senior management is in charge of patient safety.
The hospitals board of trustees is committed to improving patient safety.
Medical staff leaders are integrated into patient safety programs.
There is a dedicated budget allocated for patient safety activities.
The budget includes funding for education and training on patient safety
issues such as fall prevention.
Improved fall prevention is a priority within the facility.
The facility has implemented a fall prevention policy.
Current fall prevention goals are being addressed.
There are visible role models/champions for fall prevention.

1D: Business Case Form
Background: This tool can be used to create a high-level overview of the case for implementing
a fall prevention program. The information gathered in this tool may be presented to the senior
leader who will decide whether to support your program. For more information on who is part of
the senior leadership team, see the resource box in section 1.3 of the toolkit text.
Reference: The form was adapted from a template developed by Project Agency to help write a
business case. Available at: www.businessballs.com/project%20management%20templates.pdf.
How to use this tool: Complete the form with all the required information. In some cases, to
complete an element of the form (e.g., section on initial estimates of cost and time), additional
work will be required. This form is best suited for a hospital administrator.
Present the completed form to the senior leader who would support your program, and discuss
the potential benefits of the fall prevention initiative. This leader may also find it valuable for the
finance department to calculate the return on investment (ROI).
ROI = Net returns from improvement actions / Investment in improvement actions. Additional
information on ROI estimation is available in a companion AHRQ toolkit for hospitals at:
www.ahrq.gov/qual/qitoolkit/f1_returnoninvestment.pdf.

Business Case
Program Background (keep this brief)
General Aims
Initial Risks
Expected Outcomes
Benefits of Implementing This Program
Initial Estimates of Cost and Time

$:
Time:
Outcome of the Business Case
Decision From (Program Sponsor)
Date

1E: Resource Needs Assessment
Background: The purpose of this tool is to identify resources that are available for a fall
prevention program.
How to use this tool: Complete this checklist to assess the resources that are available and the
resources that are still needed. This assessment is best suited for hospital supervisors, managers,
and administrators.
Use this tool to ensure that all resources needed for launching a fall prevention program are
available.
Needed:
Resource Yes/No Notes on what is needed
Staff education programs
Quality improvement experts
Physical/occupational therapy consultation on
work practices
Information technology support
Specific products/tools (e.g., low beds,
floormats, assistive devices, safe patient
handling equipment)
Facilities and supplies (e.g., meeting rooms)
Printing/copying
Graphics/design
Nonclinical time for team meetings and
activities
Other
Funds

1F: Organizational Readiness Checklist
Background: This tool can be used to monitor your progress on completing the organizational
readiness activities.
How to use this tool: Complete the checklist. This assessment is best suited for hospital
supervisors, managers, and administrators.
Use this tool to ensure you have not skipped any essential steps in your fall prevention efforts.
Organizational Readiness Checklist

Readiness Question Assessment in Your Organization Yes No
Does the organization Hospital culture focuses on a systems approach
promote a culture of safety? to error reduction.
Why is change needed? Hospital-specific reasons for change have been
identified.
Do organizational members Staff attitudes about falls have been assessed.
understand why change is Assessment results have been analyzed to
needed? suggest awareness-building needs.
Is there a sense of urgency Supporters who have a sense of urgency have
about the change? been identified.
Efforts are underway to generate a sense of
urgency if lacking.
Is there leadership support Leadership support has been assessed.
for this effort? If necessary, efforts are underway to generate
this support.
Senior leader champion or sponsor has been
identified.
Who will take ownership of A leader has been identified for the fall
this effort? prevention effort.
This leader is now involved in the subsequent
planning steps.
What kinds of resources are A preliminary list of needed human and material
needed? resources has been developed.
Commitments to provide those resources have
been obtained or are forthcoming.

2A: Interdisciplinary Team
Background: Crucial to a fall prevention initiative is the creation of an interdisciplinary
Implementation Team that will oversee the improvement effort. This tool can be used to identify
people from different disciplines to take part on the Implementation Team.
How to use this tool: This tool contains three parts:
1. Use the first list provided to form your Implementation Team. This tool should be filled out
by the Implementation Team leader. List the names of possible team members from each
department or discipline and their area of expertise.
The second list provides all the tools and resources included in the toolkit and which team roles
and disciplines may be responsible for the tool. The team leader or team members can refer
to this list to access the tools and ensure that appropriate people are selected for inclusion on
the team.
The last part, a matrix, provides the team roles and disciplines that may be included on the
Implementation Team tools and the related tools and resources. Potential team members can
review the tools most relevant to them to gain a better sense of their roles and responsibilities
in fall prevention.
The core Implementation Team should be a reasonable size (e.g., 6-12 people) in order to be
effective. Additional staff may be included on an as needed basis. When you create a new
team or invite new members to a team, make sure to set aside time for introductions at the
beginning of your team meeting.

Interdisciplinary Team Tool Part 1: List of Potential Team Members
Names of Possible
Implementation Team
Position/Discipline Members From Each Area Area of Expertise
Nursing
Staff nurses
Nursing assistants
Rehabilitation
Physical therapists
Occupational therapists
Prescribing Clinicians
Physicians (e.g.,
hospitalist)
Other providers (e.g., nurse
practitioner or physician
assistant)
Pharmacy
Pharmacists
Facilities and Environment
Materials manager
Environmental services
staff
Facilities engineer
Managers
Senior manager
Quality
improvement/safety/risk
manager
Other
Information systems staff
Administrative assistant
Educator
Registered dietitian
Patient representative
Volunteer

Interdisciplinary Team Tool Part 2: List of Tools and Roles of Individuals Who Should
Use the Tool
This list provides all the tools and resources included in the toolkit and which team roles and
disciplines should use the tool. The team leader or team members can refer to this list to access
the tools and ensure that appropriate people are selected for inclusion on the team.
Notes: For some of the tools listed below, the Implementation Team leader may wish to
designate an individual to complete the tool on the teams behalf.
Items marked with an asterisk (*) can be integrated into your hospitals electronic health record
with the help of information systems staff.
Tools and Resources Who Should Use the Tool

A Introductory Executive Summary for Senior manager (e.g., Chief Executive
Stakeholders Officer or Chief
Medical/Nursing/Operating Officer)
1A Hospital Survey on Patient Safety Culture All interdisciplinary team members and
staff on units preparing to implement the
fall prevention program
1B Stakeholder Analysis Implementation Team leader (e.g., senior
manager or quality
improvement/safety/risk manager)
1C Leadership Support Assessment Implementation Team leader
1D Business Case Form Implementation Team leader
1E Resource Needs Assessment Implementation Team leader
1F Organizational Readiness Checklist Implementation Team leader
2A Interdisciplinary Team Implementation Team leader
2B Quality Improvement Process Implementation Team leader
2C Current Process Analysis Individuals designated by the
Implementation Team leader
2D Assessing Current Fall Prevention Policies Individuals designated by the
and Practices Implementation Team leader
2E Falls Knowledge Test Staff nurses and nursing assistants
2F Action Plan Implementation Team leader with quality
improvement/safety/risk manager
2G - Managing Change Checklist Implementation Team leader
3A Master Clinical Pathway for Inpatient Falls Quality improvement/safety/risk
manager, staff nurses, and nursing
assistants
3B Scheduled Rounding Protocol Unit manager, staff nurses, and nursing
assistants
3C Tool Covering Environmental Safety at the Unit manager and facility engineer
Bedside
3D Hazard Report Form Any hospital employee who enters
patient rooms

Tools and Resources Who Should Use the Tool
3E Clinical Pathway for Safe Patient Handling Nurse manager, staff nurses, and nursing
assistants
3H Morse Fall Scale for Identifying Fall Risk Staff nurses
Factors*
3G STRATIFY Scale for Identifying Fall Risk Staff nurses
Factors*
3I Medication Fall Risk Scale and Evaluation Pharmacist and staff nurses
Tools*
3F Orthostatic Vital Sign Measurement Staff nurses and nursing assistants
3J Delirium Evaluation Bundle: Digit Span, Physicians, nurse practitioners, physician
Short Portable Mental Status Questionnaire, and assistants
Confusion Assessment Method*
3K Algorithm for Mobilizing Patients* Nursing assistants
3L Patient and Family Education Educators, staff nurses
3M Sample Care Plan* Staff nurses with input from other
disciplines (e.g., physician, pharmacist,
physical and/or occupational therapists)
3N Postfall assessment, clinical review* Staff nurses and physicians
3O Postfall assessment for root cause analysis Staff nurses
3P Best Practices Checklist Implementation Team leader
4A Assigning Responsibilities for Using Best Implementation Team leader
Practices
4B Staff Roles Unit manager
4C Assessing Staff Education and Training Implementation Team leader
4D Implementing Best Practices Checklist Implementation Team leader
5A Information To Include in Incident Reports Quality improvement/safety/risk
manager, information systems staff
5B Assessing Fall Prevention Care Processes Unit manager and unit champions
5C Measuring Progress Checklist Implementation Team leader
6A Sustainability Tool Implementation Team leader

Interdisciplinary Team Tool Part 3: Matrix of Applicable Tools, by Role
This matrix lists the disciplines that may be included on the Implementation Team and shows tools and resources they may be responsible for. The
team leader or team members can use this list to access the tools and ensure that appropriate people are selected for the team.
Tools and Resources

Position/Discipline 1 2 3A 3B 3C 3D 3E 3F 3G 3H 3I 3J 3K 3L 3M 3N 3O 3P 4 5 6
Nursing
Staff nurses X X X X X X X X X X X
Nursing assistants X X X X X
Nurse manager X
Rehabilitation
Occupational therapists X
Physical therapists X
Prescribing Clinicians
Nurse practitioners X
Physicians X X X
Physician assistants X
Pharmacy
Pharmacist X X
Facilities and Environment
Facility engineer X
Managers
Quality improvement manager X X X
Risk manager X X X
Safety manager X X X
Other
Educators X
Hospital employees who enter X
patient rooms
Unit champion X
Unit manager X X X
Implementation Team leader X X X X X

Tools and Resources
Position/Discipline 1 2 3A 3B 3C 3D 3E 3F 3G 3H 3I 3J 3K 3L 3M 3N 3O 3P 4 5 6
Individuals designated by the X X X X X
Implementation Team leader

2B: Quality Improvement Process
Background: This tool will help you and your team identify the extent to which you have the
resources for quality improvement (QI) in your organization. The form was developed by the
Turning Point Initiative to assess if an organization has the needed systems in place to improve
quality and performance.
Reference: Turning Point Performance Management National Excellence Collaborative.

Performance Management Self-Assessment Tool. Available at:
www.turningpointprogram.org/toolkit/pdf/PM_Self_Assess_Tool.pdf.
How to use this tool: This tool should be filled out by the Implementation Team leader (or
individual designated by the leader) in consultation with the QI department. The you refers to
your organization as a whole. Check the box that most accurately describes your organizations
current resources. If you find that your organization has fully operationalized QI processes,
connect the fall prevention initiative with these existing processes. If some processes are
missing, advocate for them to be put into place in the context of the fall prevention program.

Quality Improvement Process
Yes (fully
Assessment Question No Somewhat operational)
Do you have a process(es) to improve quality or
performance?
Is an entity or person responsible for decisionmaking
based on performance reports (e.g., top management
team, governing or advisory board)
Is there a regular timetable for your QI process?
Are the steps in the process communicated?
Are managers and employees evaluated for their
performance improvement efforts (i.e., is
performance improvement in their job descriptions)?
Are performance reports used regularly for
decisionmaking?
Is performance information used to do the following? (check all that apply)
Determine areas for more analysis or evaluation.
Set priorities and allocate/redirect resources.
Inform policymakers of the observed or potential
impact of decisions under their consideration.
Do you have the capacity to take action to improve performance when needed?
Do you have processes to manage changes in
policies, programs, or infrastructure?
Do managers have the authority to make certain
changes to improve performance?
Do staff have the authority to make certain changes
to improve performance?
Does the organization regularly develop performance
improvement or QI plans that specify timelines,
actions, and responsible parties?
Is there a process or mechanism to coordinate QI
efforts among programs, divisions, or organizations
that share the same performance targets?
Is QI training available to managers and staff?
Are personnel and financial resources allocated to
your QI process?

2C: Current Process Analysis
Background: Before beginning a quality improvement initiative, you need to understand your
current methods. This tool can be used to describe key processes in your organization where fall
prevention activities could or should happen.
Reference: Adapted from: Quality Partners of Rhode Island. QI Worksheet E, Current Process
Analysis. Available at:
http://nhqi.hsag.com/Resource_documents/Worksheet_E_Current_Process_Analysis.pdf.
How to use this tool:
Identify who will conduct the mapping and who will be on the mapping team. The
mapping team should include at least two frontline staff on the Implementation Team and
at least one person who has experience with process maps. Try to use the same team
members if more than one process is mapped.
Have the Implementation Team identify and define every step in the current process for
fall prevention.
Define a beginning, an end, and a methodology for all of the processes to be mapped. For
example, some processes are mapped through the method of direct observation of the
process taking place, while others can be mapped by knowledgeable stakeholders talking
through and documenting each step in the process.
When defining a process, think about staff roles in the process, the tools or materials staff
use, and the flow of activities.
Everything is a process, whether it is admitting a patient, serving meals, assessing pain,
or managing a nursing unit. Identify key processes involving fall prevention. The goal of
defining a process is to hone in on patient safety vulnerabilities and potential failures in
the current process.
Examples of processes might include initial fall risk factor assessments (e.g., when does
it occur, who does it, what happens if a patient is found to have risk factors) or postfall
management.
Determine if there are any gaps and problems in your current processes, and use the results of
this analysis to systematically change these processes.

Process Analysis Procedures
Take time to brainstorm and listen to every team member.
Make sure the process is understood and documented.
Make each step in the process very specific.
Use one post-it note, index card, or scrap piece of paper for each step in the process.
Lay out each step, move steps, and add and remove steps until the team agrees on the
final process.
If a process does not exist (for example, there is no process to assess fall risk factors upon
admission and readmission), identify the related processes (for example, the process for
admission and readmission).
If the process is different for different shifts, identify each individual process.
Example: Process for Making Buttered Toast
Step Definition
1. Check to see if there is bread, butter, knife, and toaster.

2. If supplies are missing, go to the store and purchase them.
3. Check to see if the toaster is plugged in. If not, plug in the toaster.
4. Check setting on toaster. Adjust to darker or lighter as preferred.
5. Put a slice of bread in toaster.
6. Turn toaster on.
7. Wait for bread to toast.
8. When toast is ready, remove from toaster and put on plate.
9. Use knife to cut pat of butter.
10. Use knife to spread butter on toast.
Identify the steps of your defined process:

Press people for details.
At the end of the gap analysis, compile the results in a document that displays each step
so that team members have the map of the current process in front of them during the
team discussion (Step 2).
Hold team discussion.

Evaluate your current process as you define it:
What policies and procedures do we have in place for this process?
What forms do we use?
How does our physical environment support or hinder this process?
Which staff are involved in this process?
Which parts of this process do not work?
Do we duplicate any work unnecessarily? Where?
Are there any delays in the process? Why?
Continue asking questions that are important in learning more about this process.

2D: Assessing Current Fall Prevention Policies and Practices
Background: The purpose of this self-assessment tool is to identify what processes of care your
hospital has in place and what areas need improvement.
Reference: Adapted from AHRQ publication on the Falls Management Program for nursing
homes. www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm.
How to use this tool: This tool should be filled out by the Implementation Team leader. Use
your hospitals policies, procedures, and general practices to answer the questions.
The results from this self-assessment can help you identify which areas need improvement and
develop a plan.

Current Fall Prevention Policies and Practices
A. Culture, Organizational Commitment, and Team Skills Yes No Comments
1. Updated policies and procedures for a comprehensive fall prevention program?
2. Appointed falls team leader and resource person for staff?
3. Selection of staff members for interdisciplinary falls team?
4. Monthly falls team meeting using ground rules, leader, timekeeper, and recorder?
5. High-level managers attend team meetings periodically and monitor falls data at least quarterly?
6. No blame/no shame environment with honest investigation and reporting by staff?
7. Celebration of success stories and rewards for caregivers who reduce falls?
8. Adequate staffing for team leader to spend 8 hours/week and team to meet for 60 minutes/month?
9. Funds for adaptive equipment and environmental modifications?
10. Employee orientation materials emphasize importance of and hospital commitment to patient
safety?
B. Data Collection and Analysis Yes No Comments
1. Accurate completion of fall incident report form by all staff?
2. Monthly falls analysis by: location and time of fall
shift and day of week
type of injury
3. Monthly falls analysis computed as falls/1,000 patient-days?
4. Falls data reported to hospital management every quarter?
5. Feedback about falls data given to direct care staff each month?
6. Falls data trended over 6 months or more?

C. Staff Training and Information for Patients and Families Yes No Comments
1. Education on fall prevention during new employee orientation and training?
2. Annual inservice training on fall prevention for all staff?
3. Staff education materials, including:
Hospital policies and procedures
Fall risk factors and consequences of falls
High-risk medications, sleep hygiene measures for management of anxiety
Low blood pressure precautions
Low vision precautions
Safety during transfer, ambulation, and wheelchair use
Unsafe behaviors, monitoring devices, and management strategies
Environment and equipment safety hazards and methods for improvement
Foot care and footwear
4. All nurses trained in a fall response system that includes:
Immediate evaluation and increased monitoring of patient
Investigation of fall circumstances
Documentation of fall
Immediate intervention within first 8 hours
5. Information for families and patients on fall risk reduction?
6. Medical staff given information about the program and their role?
D. Environment and Equipment Safety Yes No Comments
1. Regular inspection of all resident rooms and bathrooms for safety problems, including:
Clutter
Poor or insufficient lighting
Unstable furniture
Hard-to-reach personal items
Unsafe flooring
Foot care and footwear
2. All staff trained to inspect and report environmental and equipment safety problems?
3. Repair of reported safety problems in a timely manner by maintenance staff?
4. Inspection and repair of all wheelchairs, canes, and walkers every 6 months?
5. Communications and inspections documented for ongoing monitoring and accountability?

2E: Fall Knowledge Test
Background: The purpose of this tool is to assess general staff knowledge on fall prevention.
Reference: Adapted from Singapore Ministry of Health Nursing Clinical Practice Guidelines on
Prevention of Falls in Hospitals and Long Term Care Institutions and subsequent version by Dr.
Serena Koh. Previously used in Koh SLS. Singapore Med J 2009;50(4):425. Original may be
found at
www.moh.gov.sg/content/dam/moh_web/HPP/Nurses/cpg_nursing/2005/prevention_of_falls_in
_hosp_ltc_institutiions.pdf.
How to use this tool: Administer the questionnaire to staff nurses and nursing assistants. The
survey may need to be modified if certain questions are not consistent with your policies and
procedures, or for the needs of specific hospital units.
Use the findings to assess gaps in knowledge. Work with your education department to tailor
specific education programs to the needs of your staff.

Fall Knowledge Test
Each question may have more than one option as the correct answer.
Please circle the letters that correspond to the correct answers.
1. Which of the following statements is correct?
a. Falls have multifactorial etiology, so fall prevention programs should comprise

multifaceted interventions.
b. Regular review of medication can help to prevent patient falls.
c. The risk of falling will be lessened when a patients toileting needs are met.
d. The use of antipsychotic medications is associated with an increased risk of falls in older
adults.
2. A multifaceted intervention program should include:
a. Individually-tailored fall prevention strategies

b. Education to patient/family and health care workers
c. Environmental safety
d. Safe patient handling
3. Risk factors for falls in the acute hospital include all of the following except:
a. Dizziness/vertigo
b. Previous fall history
c. Antibiotic usage
d. Impaired mobility from stroke disease
4. Which of the following statements is true?
a. The cause of a fall is often an interaction between patients risk, the environment, and
patient risk behavior.
b. Increase in hazardous environments increases the risk of falls.
c. The use of a patient identifier (e.g., identification bracelet) helps to highlight to staff
those patients at risk for falls.
d. A fall risk assessment should include review of history of falls, mobility problems,
medications, mental status, continence, and other patient risks.
5. Patients with impaired mobility should be:
a. Confined to bed
b. Encouraged to mobilize with assistance
c. Assisted with transfers
d. Referred for exercise program or prescription of walking aids as appropriate

6. The management of the acutely confused patient should include all of the following except:
a. Moving patients away from the nursing station

b. Involving family members to sit with the patient
c. Orienting patients to the hospital environment
d. Reinforcing activity limits to patients and their families
7. Which of the following statements is false?
a. Fall prevention efforts are solely the nurses responsibility.

b. A patient who is taking four or more oral medications is at risk for falling.
c. A patient who is taking psychotropic medication is at higher risk for falling.
d. Testing or treatment for osteoporosis should be considered in patients who are at high
risk for falls and fractures.
8. In hospital settings, intervention programs should include:
a. Staff education on fall precautions

b. Provision and maintenance of mobility aids
c. Postfall analysis and problem-solving strategy
d. Bed alarms for all patients, regardless of risk
9. When assessing patients, which of the following statements is false?
a. All patients should be assessed for fall risk factors at admission, at a change in status,
after a fall, and at regular intervals.
b. Medication review should be included in the assessment.
c. All patients should have their activities of daily living and mobility assessed.
d. Environmental assessment is not important in the hospital as it is all standardized.
10. Risk factors for falls include:
a. Parkinsons disease
b. Incontinence
c. Previous history of falls
d. Delirium
11. Exercise programs for ambulatory older adults should:
a. Be very aggressive
b. Be unsupervised
c. Be ongoing
d. Include individualized strength and balance training

12. Which of the following statements on education in fall prevention is false?
a. Education programs should target primarily health care providers, patients, and
caregivers.
b. Education programs for staff should include the importance of fall prevention, risk
factors for falls, strategies to reduce falls, and transfer techniques.
c. Instruction on safe mobility, with emphasis on high-risk patients, should be provided to
both patients and families.
d. Education should only be given at the start of the fall prevention program.
13. Which of the following is recommended to improve patient safety?
a. Locking wheeled furniture when it is stationary.

b. Having nonslip flooring.
c. Placing frequently used items (including call bell, telephone, and remote control) within
reach of the patient
d. Rounding hourly to address patient needs
Answer Key:
1. A, B, C
2. A, B, C, D
3. C
4. A, B, C, D
5. B, C, D
6. A
7. A
8. A, B, C
9. D
10. A, B, C, D
11. C, D
12. D
13. A, B, C, D

2F: Action Plan
Background: The purpose of this tool is to provide a framework for outlining steps that will be
needed to design and implement the fall prevention initiative.
Reference: Adapted from material produced by MassPro, a participant in the Centers for
Medicare & Medicaid Services Quality Improvement Organization Program.
How to use this tool:
This tool should be filled out by the Implementation Team leader in consultation with the quality
improvement manager.
1. Note the date and the objective. A sample objective is provided.

2. The form lists six key tasks. For each, list in the second column the steps that will be
taken to address the task, including tools to be used.
3. In developing the plan, it is not expected that you will provide results, only that you will
lay out what needs to be done.
4. In the last two columns, determine who will have lead responsibility for completing each
task, and estimate an appropriate timeframe for completing the activities.
5. Use the plan as a working document that can be revised. As you begin to carry out the
plan, you may need to make adjustments and add details to the later tasks.
Use the completed sheet to plan, manage, and carry out the identified tasks. The plan should
guide the implementation process and can be continually amended and updated.
A sample completed form is shown below, followed by a blank form.

Fall Prevention Action Plan Date: November 16, 2011
Improvement Objective: Implement standard fall prevention practices within 6 months.

Team Members
Responsible for Task Target Date for Task
Key Interventions/Tasks Steps To Complete Task and Tools To Use Completion Completion
Examples Examples Examples
Analyze current state of fall Identify strengths and weaknesses using Team leader, RNs Within 6 weeks from
prevention practices in this process mapping and gap analysis. Tool 2C initiative start
organization. and Tool 2D.
Assess the current state of staff knowledge Education department Within 6 weeks from
about fall prevention. Tool 2E. initiative start
Set target goals for improvement. QI department Within 8 weeks from
initiative start
Identify the set of prevention Determine how comprehensive universal Implementation Team Within 12 weeks from
practices to be used in fall precautions should be performed. initiative start
redesigned system. Decide which scale or questions will be Implementation Team Within 12 weeks from
used for performing fall risk factor initiative start
assessment.
Decide which fall prevention activities Clinical staff members Within 12 weeks from
should be in your program. initiative start
Assign roles and responsibilities Determine who will complete the fall risk Implementation Team Within 16 weeks from
for implementing the redesigned factor assessment on admission. Tool 4A. initiative start
fall prevention practices. Identify unit champions. Team leader Within 16 weeks from
initiative start
Determine how prevention work will be QI team Within 16 weeks from
organized at the unit level, such as paths of initiative start
communication and lines of oversight.
Put the redesigned set into Engage staff and get them excited about the Team leader, unit staff Within 12 weeks from
practice. changes needed. initiative start
Pilot test the new practices. QI department Within 20 weeks from
initiative start

Team Members
Responsible for Task Target Date for Task
Key Interventions/Tasks Steps To Complete Task and Tools To Use Completion Completion
Examples Examples Examples
Monitor fall rates and practices. Determine how incidence data on fall rates QI department Within 6 weeks from
and fall prevention care processes will be initiative start
collected. Tools 5A and 5B.
Organize quarterly reviews of data. QI department Within 6 weeks from
initiative start, ongoing
Sustain the redesigned Ensure continued leadership support. Team leader Within 4 weeks from
prevention practices. initiative start, ongoing
Ensure ongoing support from other units IT, facilities Within 40 weeks from
such as facilities management and IT. management, PT, initiative start
dietitians
Designate responsibility and accountability Team leader and Within 40 weeks from
for fall prevention oversight and continuous Implementation Team initiative start
quality improvement.

Fall Prevention Action Plan Date:
Improvement Objective:
Team Members
Steps To Complete Task and Tools To Responsible for Task Target Date for Task
Key Interventions/Tasks Use Completion Completion
Analyze current state of fall
prevention practices in this
organization.
Identify the set of prevention

practices to be used in redesigned
system.
Assign roles and responsibilities for

implementing the redesigned fall
prevention practices.
Put the redesigned care processes

into practice.
Monitor fall rates and practices.
Sustain the redesigned prevention

practices.

2G: Managing Change Checklist
Background: This tool can be used to monitor your progress on completing the managing
change activities.
How to use this tool: The Implementation Team leader (or individual designated by the leader)
should complete the checklist upon starting his/her role as leader and review the checklist
quarterly thereafter.
Managing Change Checklist

Implementation Team composition
Team leader identified and in place
Members with necessary expertise/role identified and invited
Linkage to senior leadership defined and established
Team startup
Team agenda and charge clearly stated
Necessary training and resources in place for team to get started
Assessment
Current state of fall prevention practice and knowledge assessed
Current practice and policies systematically examined
Challenges to good practice identified at organization and unit levels
Staff knowledge assessed
Starting the work of redesign
Approaches to redesign explored and chosen
Gap analysis conducted between current practice and recommended practice
Setting goals and plans for change
Specific goals set
Plan initiated for making changes to meet those goals
Preliminary plan in place for sustaining the changes

3A: Master Clinical Pathway for Inpatient Falls
Background: The purpose of this tool is to provide an overview of how fall prevention care
processes could occur at your hospital or hospital unit.
How to use this tool: Compare the master clinical pathway to your current activities and adapt
your activities or the master clinical pathway as needed to suit your specific circumstances.
This tool can be used by the quality improvement manager, staff nurses, and nursing assistants as
an aid in designing a new system, as a training tool, or as an ongoing clinical reference tool. This
tool can be modified or a new one created to meet the needs of your particular setting. If you
prepared a process map describing your current practices, you can compare that with desired
practices outlined on the clinical pathway.

Inpatient Falls Clinical Pathway

3B: Scheduled Rounding Protocol
Background: Hourly rounds are an opportunity to ensure that universal fall precautions are
implemented and that patients needs are being met. These rounds integrate fall prevention
activities with the rest of a patients care.
Reference: Adapted from Meade CM, Bursell AL, Ketelsen L. Effects of nursing rounds: on
patients call light use, satisfaction, and safety. Am J Nurs 2006;106(9):58-70 with permission.
Items that have been modified or added are marked with an asterisk.
How to use this tool: Review the hourly rounding protocol and adapt it to your specific
circumstances. For example, components of the fall risk factor assessment can be added, such as
a brief mental status screen.
This protocol can be used by staff nurses, nursing assistants, and the unit manager to ensure that
universal fall precautions are in place.
The following items should be checked and performed for each patient. Upon entering the room,
tell the patient you are there to do your rounds.
1 Assess patient pain levels using a pain-assessment scale (if staff other than RNs are doing
the rounding and the patient is in pain, contact an RN immediately so the patient does not
have to use the call light for pain medication).
2 Put medication as needed on RNs scheduled list of things to do for patients and offer the
dose when due.
3 Offer toileting assistance.
4 Check that patient is using correct footwear (e.g., specific shoes/slippers, nonskid socks).*
5 Check that the bed is in locked position.*
6 Place hospital bed in low position when patient is resting; ask if patient needs to be
repositioned and is comfortable.*
7 Make sure the call light/call bell button is within the patients reach and patient can
demonstrate use.*
8 Put the telephone within the patients reach.
9 Put the TV remote control and bed light switch within the patients reach.
10 Put the bedside table next to the bed or across bed.*
11 Put the tissue box and water within the patients reach.
12 Put the garbage can next to the bed.
13 Prior to leaving the room, ask, Is there anything I can do for you before I leave? I have
time while I am here in the room.
14 Tell the patient that a member of the nursing staff (use names on white board) will be
back in the room in an hour to round again.

3C: Tool Covering Environmental Safety at the Bedside
Background: Facility safety is key to preventing falls in the hospital.
Reference: Adapted from AHRQ publication on the Falls Management Program for nursing
homes. Available at: www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm.
How to use this tool: This tool contains an inspection checklist to be completed jointly by the
unit manager and facility engineer to identify and resolve environmental safety issues in hospital
rooms. The inspection is designed to be performed room by room and bed by bed within each
room (if rooms are not private).
Use the results from the inspection process to determine which items require attention by the
nursing staff or maintenance or replacement by the facility engineers. Additional guidance for
engineers about maintenance and repairs may be found at:
www.ahrq.gov/research/ltc/fallspx/fallspxmanapd.htm.

Inspection List
Write the unit name, date, and room numbers across the top line. Put the bed number or letter across the second line and sign it. Put an X under the
room number and bed beside all the tasks that need to be done (leave blank if no safety issue is identified or problem can be fixed immediately).
Indicate whether this task should be completed by the nursing staff or facilities staff in the Assigned column. Tasks that are typically completed by
the facility engineers are denoted with an (f). Write notes about special problems or add details in the Notes column.
Unit Date: Room Number: Assigned to Notes

Signature: Bed:
1. Paths Remove unused equipment (canes/walkers).
Remove bedside commode, if unused.
With patients permission, rearrange room to clear
paths.
Put the bedside table next to the bed or across bed.
Remove unused items from bathroom and store
elsewhere.
Make tiebacks for divider curtains. (f)
Tie electrical cords out of path (TV, phone). (f)
2. Furniture Adjust bed into locked position.
Replace unstable bed with a stable one.
Push bed to wall (check local and state fire codes).
Remove all lightweight or unstable furniture.
Clean, repair, or replace broken bed wheel locks. (f)
Fix unstable furniture. (f)
Secure loose bathroom handrails. (f)
Replace missing rubber tips on bedside commode. (f)
Replace missing rubber tips on handrails that rest on (f)
floor.
Secure raised toilet seat to commode. (f)
3. Easy Arrange room so that items are within patients reach (f)
Access (e.g., walking aids are within safe reach).
4. Floor Repair or replace floor covering. (f)
Replace high, broken, or missing thresholds. (f)
Add grading to thresholds between room and (f)
bathroom.

5. Lighting Replace burned out or flickering bulbs. Use max (f)
wattage.
Repair broken room lights or call lights. (f)
Replace broken call light cords or lengthen cords. (f)
6. Equipment Inspect wheelchair (for all wheelchairs found). (f)
Repair cane. (f)
Repair walker. (f)

3D: Hazard Report Form
Background: This tool contains a form for reporting environmental hazards when they are
detected. Whereas the inspection checklist (Tool 3C, Tool Covering Environmental Safety at
the Bedside) is for regular, systematic review for fall hazards, this form is for hazards detected
incidentally during usual care.
Reference: Falls prevention strategies in health care settings. Plymouth Meeting, PA: ECRI
Institute; 2006. Hazard Report Form 13: 248. Reprinted with permission.
How to use this tool: Use this form whenever an environmental hazard is detected. You may
need to change the people to whom the hazard is reported based on your local organizational
setup. Any hospital employee who enters patient rooms can use this form.

Hazard Report Form
To: Nurse Manager

Equipment or Condition Presenting Hazard:
Location of Hazard:
Date Hazard Reported:
Hazard Reported by (your name):
Corrective Action Taken (describe what you did to eliminate the hazard):
Work Order Initiated (describe what still needs to be done to eliminate the hazard):
Work Order Completed on:
Work Order Completed by:
Action Taken to Eliminate Future Occurrences:
Hazard Reported at:

Staff Meeting (date):
Shift Reports (date):
Posting on Bulletin Boards (date):
Copies of this form must be forwarded to the Risk Manager.
Reprinted with permission. 2006, ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA
19462, www.ecri.org.

3E: Clinical Pathway for Safe Patient Handling
Background: This tool is a clinical pathway that illustrates appropriate application of safe
patient handling principles, which are part of universal fall precautions (described in more detail
in section 3).
Reference: Developed by VA Sunshine Healthcare Network (VISN 8) Patient Safety Center of

Inquiry, Tampa, Florida.
How to use this tool: Use this and other safe patient handling pathways available at:
www.visn8.va.gov/VISN8/PatientSafetyCenter/safePtHandling/SafePatientHandlingAssessment
_Algorithms_031209.doc as a guideline to compare against your current care processes for safe
patient handling. Additional training on safe patient handling for frontline staff is available from
the Centers for Disease Control and Prevention at www.cdc.gov/niosh/docs/2009-
127/default.html.
This tool can be used by the nurse manager, staff nurses, and nursing assistants as an aid in
designing a new system, as a training tool, or as an ongoing clinical reference tool. This tool can
be modified or a new one created to meet the needs of your particular setting.

3F: Orthostatic Vital Sign Measurement
Background: This tool can be used to identify orthostatic hypotension, a risk factor for falls in
hospitalized patients.
Reference: Adapted from: John Dempsey Hospital Department of Nursing Clinical

Manual/Nursing Practice Manual (available at:
http://nursing.uchc.edu/nursing_standards/docs/Orthostatic%20(Postural)%20Vital%20Sign%20
Measurement.pdf ) with information from MaineHealth Cardiovascular Health (available at:
www.mainehealth.org/workfiles/mh_healthinformation/Measuring_Orthostatic_Vital_Signs.pdf)
.
How to use this tool: Staff nurses and nursing assistants typically complete this protocol. All
findings should be reported to the treating medical provider. The decision whether to use this
protocol on all patients (e.g., on admission), or as needed, will depend on the specific unit.
However, consider checking orthostatic vital signs:
After a fall.
When a patient complains of a symptom that may be due to orthostasis (e.g.,
lightheadedness).
As part of a routine admission assessment on units where patients frequently take
medications that cause orthostasis (e.g., geriatric psychiatry).
When a patient is on a medication that may cause orthostasis and has other risk factors
for falls.
Use this tool in conjunction with clinical assessment and a standard assessment of fall risk
factors (e.g., Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors, or Tool 3G,
STRATIFY Scale for Identifying Fall Risk Factors) to determine a patients risk factors for
falls, and then plan care accordingly.

Protocol for Orthostatic (Postural) Vital Sign Measurement
Policy
1. Orthostatic vital signs may be indicated to evaluate patients who are at risk for hypovolemia
(vomiting, diarrhea, bleeding), have had syncope or near syncope (dizziness, fainting), or are
at risk for falls. A significant change in vital signs with a change in position also signals
increased risk for falls.
Orthostatic vital signs are not indicated in patients who:
e. Have supine hypotension.

f. Have a sitting blood pressure 90/60.
g. Have acute deep vein thrombosis.
h. Exhibit the clinical syndrome of shock.
i. Have severely altered mental status.
j. Have possible spinal injuries.
k. Have lower extremity or pelvic fractures.
l. Are not mobile enough to get out of bed.
Orthostatic vital signs (blood pressure, pulse, and symptoms) will be obtained and recorded
while the patient is in the supine position as well as in the standing position. If the patient is
unable to stand, orthostatics may be taken while the patient is sitting with feet dangling.
Equipment
Noninvasive blood pressure measurement device.

Blood pressure cuff of correct size for the patient.
Procedure
1. Instruct the patient on the process of orthostatic blood pressure measurement and its
rationale.
2. Assess by verbal report and observation the patients ability to stand.
3. Have patient lie in bed with the head flat for a minimum of 3 minutes, and preferably 5
minutes.
4. Measure the blood pressure and the pulse while the patient is supine.
5. Instruct patient to sit for 1 minute.
a. Ask patient about dizziness, weakness, or visual changes associated with position change.
Note diaphoresis or pallor.
b. Check sitting blood pressure and pulse.
c. If the patient has symptoms associated with position change or sitting blood pressure
90/60, put patient back to bed.

6. Instruct patient to stand.
a. Ask patient about dizziness, weakness, or visual changes associated with position change.
Note diaphoresis or pallor.
b. If patient is unable to stand, sit patient upright with legs dangling over the edge of the
bed.
c. The patient should be permitted to resume a supine position immediately if syncope or
near syncope develops.
7. Measure the blood pressure and pulse immediately after patient has stood up, and then repeat
the measurements 3 minutes after patient stands. Support the forearm at heart level when
taking the blood pressures to prevent inaccurate measurement.
8. Assist patient back to bed in a position of comfort.
9. Document vital signs and other pertinent observations on the nursing flowsheet or in the
medical record. Note all measurements taken and the position of the patient during each
reading.
Evaluation
1. Subtract values 3 minutes after standing (or if patient cannot stand, then sitting) from lying
values.
A decline of 20mm Hg in systolic or 10 mm Hg in diastolic blood pressure after 3 minutes

of standing = orthostatic hypotension.
A heart rate increase of at least 30 beats per minute after 3 minutes of standing may suggest
hypovolemia, independent of whether the patient meets criteria for orthostatic hypotension.
A blood pressure drop immediately after standing that resolves at 3 minutes does not indicate
orthostatic hypotension. However, this finding may be useful to confirm a patients
complaint of feeling dizzy upon standing and may lead to patient education about using
caution when arising from a lying or sitting position.
Report all findings to the treating medical provider, including all sets of blood pressure and
pulse results, and whether the patient experienced pallor, diaphoresis, or faintness when
upright.
Sometimes it may be difficult to determine if the resident/patient has orthostatic hypotension

when checking only at one point in time. If the resident/patient does not show evidence of
orthostatic hypotension during the assessment but has complained of lightheadedness or
dizziness, perform the measurements when the resident/patient complains or within 2 hours of the
start of a meal.

3G: STRATIFY Scale for Identifying Fall Risk Factors
Background: This tool can be used to identify risk factors for falls in hospitalized patients. The
total score may be used to predict future falls, but it is more important to identify risk factors
using the scale and then plan care to address those risk factors.
Reference: Adapted from Oliver D, Britton M, Seed P, et al. Development and evaluation of
evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall:
case-control and cohort studies. BMJ 1997;315(7115):1049-53. Reprinted with permission from
BMJ Group.
How to use this tool: Please fill out the scale as instructed below. This tool can be used by staff
nurses.
Use this tool in conjunction with clinical assessment and a review of medications (see Tool 3I) to
determine if a patient is at risk for falls and plan care accordingly. Note that this scale may not
capture the risk factors that are most important on your hospital ward, so consider your local
circumstances.
If your hospital uses an electronic health record, consult your hospitals information systems
staff about integrating this tool into the electronic health record.

STRATIFY Risk Assessment Tool
Answer all five questions below and count the number of Yes answers.
1 Did the patient present to hospital with a fall or has he or she fallen Yes = 1 No = 0
on the ward since admission (recent history of fall)?
2 Is the patient agitated? Yes = 1 No = 0
3 Is the patient visually impaired to the extent that everyday function Yes = 1 No = 0
is affected?
4 Is the patient in need of especially frequent toileting? Yes = 1 No = 0
5 Does the patient have a combined transfer and mobility score of 3 Yes = 1 No = 0
or 4? (calculate below)
Transfer score: Choose one of the following options which best
describes the patients level of capability when transferring from a
bed to a chair:
0 = Unable
1 = Needs major help
2 = Needs minor help
3 = Independent
Mobility score: Choose one of the following options which best
describes the patients level of mobility:
0 = Immobile
1 = Independent with the aid of a wheelchair
2 = Uses walking aid or help of one person
3 = Independent
Combined score (transfer + mobility): ____________
Total score from questions 1-5: ___________
0 = Low risk
1 = Moderate risk
2 or above = High risk

3H: Morse Fall Scale for Identifying Fall Risk Factors
Background: This tool can be used to identify risk factors for falls in hospitalized patients. The
total score may be used to predict future falls, but it is more important to identify risk factors
using the scale and then plan care to address those risk factors.
Reference: Adapted from Morse JM, Morse RM, Tylko SJ. Development of a scale to identify
the fall-prone patient. Can J Aging 1989;8:366-7. Reprinted with the permission of Cambridge
University Press.
How to use this tool: A training module on proper use of the Morse Fall Scale developed by the
Partners HealthCare Fall Prevention Task Force may be found at
www.brighamandwomens.org/Patients_Visitors/pcs/nursing/nursinged/Medical/FALLS/Fall_TI
PS_Toolkit_MFS%20Training%20Module.pdf. In addition to completion of the module, training
should include real cases where the provider conducts an assessment. Mental status and gait
parameters require actual assessment of a real patient (as opposed to solely a chart review).
This tool can be used by staff nurses. Use this tool in conjunction with clinical assessment and a
review of medications (see Tool 3I) to determine if a patient is at risk for falls and plan care
accordingly. Note that this scale may not capture the risk factors that are most important on your
hospital ward, so consider your local circumstances.
Register through Partners HealthCare at

www.brighamandwomens.org/Patients_Visitors/pcs/nursing/nursinged/Medical/FALLS/Permissi
ons/PHS%20MFS%20Competency.pdf prior to use.

Morse Fall Scale
Item Item Score Patient Score
1. History of falling (immediate or previous) No 0
Yes 25 ______
2. Secondary diagnosis ( 2 medical diagnoses in chart) No 0
Yes 15 ______
3. Ambulatory aid
None/bedrest/nurse assist Crutches/cane/walker 0
Furniture 15
30 ______
4. Intravenous therapy/heparin lock No 0
Yes 20 ______
5. Gait
Normal/bedrest/wheelchair 0
Weak* 10
Impaired 20 ______
6. Mental status
Oriented to own ability 0
Overestimates/forgets limitations 15 ______
Total Score: Tally the patient score and record.
<25: Low risk
25-45: Moderate risk
>45: High risk ______
* Weak gait: Short steps (may shuffle), stooped but able to lift head while walking, may seek support from furniture
while walking, but with light touch (for reassurance).
Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down; significantly impaired
balance, requiring furniture, support person, or walking aid to walk.
Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to identify the fall-prone
patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse herself said that the appropriate cut-points to
distinguish risk should be determined by each institution based on the risk profile of its patients. For details, see
Morse JM, , Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging
1989;8;366-7.

3I: Medication Fall Risk Score and Evaluation Tools
Background: This tool can be used to identify medication-related risk factors for falls in
hospitalized patients. A pharmacist would perform this assessment.
Reference: Used with permission: Beasley B, Patatanian E. Development and implementation of

a pharmacy fall prevention program. Hosp Pharm 2009;44(12):1095-1102. 2009, Thomas
Land Publishers, www.hosp-pharmacy.com.
How to use this tool: Evaluate medication-related fall risk on admission and at regular intervals
thereafter. Add up the point value (risk level) for every medication the patient is taking. If the
patient is taking more than one medication in a particular risk category, the score should be
calculated by (risk level score) x (number of medications in that risk level category). For a
patient at risk, a pharmacist should use the evaluation tools to determine if medications may be
tapered, discontinued, or changed to a safer alternative.
Use this tool in conjunction with clinical assessment and a nursing risk scale (e.g., Tool 3H,
Morse Fall Scale for Identifying Fall Risk Factors, or 3G, STRATIFY Scale for Identifying
Fall Risk Factors) to determine if a patient is at risk for falls and plan care accordingly. Note
that this scale may not capture the medication risk factors that are most important on your
hospital ward, so consider your local circumstances.* A hybrid approach is to have the nurse use
a scale such as the one below and alert the pharmacist if the total score is 6 or greater.
* Formularies may differ. Consult the hospital pharmacy and therapeutics committee or
pharmacy department for formulary drugs within the American Hospital Formulary Service drug
class identified in the table. The hospital can decide how to specify the drugs that fall within
these risk classes. Also consider the dose and timing of medications (e.g., avoiding diuretic use
close to bedtime).

Medication Fall Risk Score
Point Value American Hospital
(Risk Level) Formulary Service Class Comments
3 (High) Analgesics,* antipsychotics, Sedation, dizziness, postural disturbances,
anticonvulsants, altered gait and balance, impaired
benzodiazepines cognition
2 (Medium) Antihypertensives, cardiac Induced orthostasis, impaired cerebral
drugs, antiarrhythmics, perfusion, poor health status
antidepressants
1 (Low) Diuretics Increased ambulation, induced orthostasis
Score 6 Higher risk for fall; evaluate patient
* Includes opiates.
Although not included in the original scoring system, the falls toolkit team recommends that you include non-
benzodiazepine sedative-hypnotic drugs (e.g., zolpidem) in this category.
Medication Fall Risk Evaluation Tools
Use the tools below when evaluating patients found to have high medication-related risk for
falls. The comments section provides information on how to evaluate the indicators.
Indicator Comments
Medications Beers criteria,* dose adjustment for renal function or disease state,
overuse of medications, IV access
Laboratory Therapeutic drug levels (digoxin, phenytoin), international normalized
ratio, electrolytes, hemoglobin/hematocrit
Disease states Comorbidities, hypertension, congestive heart failure, diabetes,
orthopedic surgery, prior fall, dementia, other
Education Patients ability/willingness to learn, patients mental status
* Beers criteria are available at: American Geriatrics Society updated Beers criteria for potentially inappropriate
medication use in older adults. J Am Geriatr Soc 2012;60(4):616-31.
Age 65 years or older.

3J: Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status
Questionnaire, and Confusion Assessment Method
Background: Patients found to have impaired mental activity as a risk factor for falls require
further evaluation. The Delirium Evaluation Bundle is designed to help determine if the patient
has delirium.
Reference:
Digit Span: Scoring guidelines from Montreal Cognitive Assessment are available at the
Veterans Affairs (VA) Web page for the National Parkinsons Disease Research, Education, and
Clinical Center & VA PD Consortium, www.parkinsons.va.gov/consortium/moca.asp.
Short Portable Mental Status Questionnaire: Adapted from (1) Hospital Elder Life Program and
(2) Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain
deficit in elderly patients. J Am Geriatr Soc 1975;23:433-41.
Confusion Assessment Method: Adapted from Inouye SK, van Dyck CH, Alessi CA, et al.
Clarifying confusion. Ann Intern Med 1990;113(12):941-8.
How to use this tool: A proper evaluation for delirium requires both standardized testing and
direct observation of the patients behavior. Performing the Digit Span Test and the Short
Portable Mental Status Questionnaire will provide information that can be used in the Confusion
Assessment Method (CAM). Instructions for each test are explained below. Use the provided
link to access the CAM training manual.
This tool should be used in any patient whose mental status is unclear on admission or transfer to
a unit, or whose mental status has acutely declined. The tool will allow you to determine if a
patient is delirious and therefore requires further medical evaluation for delirium. Physicians,
nurse practitioners, and physician assistants can carry out this assessment, but training is required
(use links provided below to access material). The training is particularly important to
distinguish delirium from behavioral symptoms of dementia.
Consider having clinical champions for delirium assessment who can be called in to evaluate a
patient if needed. If your hospital uses an electronic health record, consult your hospitals
information systems staff about integrating this tool into the electronic health record.

Digit Span
Now I am going to say some numbers. Please repeat them back to me.
[SAY DIGITS AT RATE OF ONE PER SECOND]
DIGITS FORWARD (DF) Response
2-9-1 ____ - ____ - ____
3-5-7-4 ____ - ____ - ____ - ____
6-1-9-2-7 ____ - ____ - ____ - ____ - ____
Now I am going to read some more numbers, but I want you to repeat them in backward order
from the way I read them to you. So, for example, if I said 6-4, you would say 4-6.
[SAY DIGITS AT RATE OF ONE PER SECOND]
DIGITS BACKWARD (DB) Response
7-42 ____ - ____ - ____
5-3-8-4 ____ - ____ - ____ - ____
SCORING: Patients should be able to repeat 5 digits forward and 3 digits backward under
normal conditions. Inability to do so represents an abnormal test result.

Short Portable Mental Status Questionnaire
Question Response Error?
What are the date, month, and year?* Date Month Year
What is the day of the week?
What is the name of this place?
What is your phone number?
How old are you?
When were you born?
Who is the current president?
Who was the president before him?
What was your mothers maiden name?
Can you count backward from 20 by 3s?
*A mistake on ANY part of this question should be scored as an error.
Total Errors: _______
SCORING*:
0-2 errors: normal mental functioning
3-4 errors: mild cognitive impairment
5-7 errors: moderate cognitive impairment
8 or more errors: severe cognitive impairment
*One more error is allowed in the scoring if a patient has had a grade school education or less. One less error is
allowed if the patient has had education beyond the high school level.
The Short Portable Mental Status Questionnaire was originally published as Pfeiffer E. A short portable mental
status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23:433-41.
The version shown here is adapted from the Hospital Elder Life Program (www.hospitalelderlifeprogram.org ). Used
with permission. E. Pfeiffer, 1994.

Confusion Assessment Method
After checking the patients orientation and performing the Digit Span Test and Short Portable
Mental Status Questionnaire, rate the patient using the Confusion Assessment Method. This is
best done after going through a training process, available at www.hospitalelderlifeprogram.org.
After agreement to conditions of use, download the Confusion Assessment Method Training
Manual at
www.hospitalelderlifeprogram.org/pdf/TheConfusionAssessmentMethodTrainingManual.pdf.
A brief summary of the Confusion Assessment Method for nurses is also available through the
Hartford Institute for Geriatric Nursing at:
http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf.
A 50-minute training video for nurses is available through the Hartford Institute for Geriatric
Nursing at: http://consultgerirn.org/resources/media/?vid_id=4361983#player_container.
To rate the patient with the Confusion Assessment Method, use the worksheet on the next page.

Confusion Assessment Method Shortened Version Worksheet
EVALUATOR: DATE:
I. ACUTE ONSET AND FLUCTUATING COURSE BOX 1

a. Is there evidence of an acute change in mental status from
the patients baseline? No Yes
b. Did the (abnormal) behavior fluctuate during the day, that

is, tend to come and go or increase and decrease in severity? No Yes
II. INATTENTION
Did the patient have difficulty focusing attention, for

example, being easily distractible or having difficulty
keeping track of what was being said? No Yes
III. DISORGANIZED THINKING
Was the patients thinking disorganized or incoherent, such BOX 2

as rambling or irrelevant conversation, unclear or illogical
flow of ideas, or unpredictable switching from subject to
subject? No Yes
IV. ALTERED LEVEL OF CONSCIOUSNESS
Overall, how would you rate the patients level of

consciousness?
Alert (normal)
Vigilant (hyperalert)
Lethargic (drowsy, easily aroused)
Stupor (difficult to arouse)
Coma (unarousable)
Do any checks appear in this box? No Yes
If all items in Box 1 are checked and at least one item in Box 2 is checked, a diagnosis of
delirium is suggested.
2003, Hospital Elder Life Program. Adapted from Inouye SK, van Dyck CH, Alessi CA, et al, Clarifying
confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med
1990;113(12):941-8.

3K: Algorithm for Mobilizing Patients
Background: The purpose of this tool is to provide a sample algorithm for mobilization of
patients. The mobility algorithm is meant for patients who have experienced deconditioning or
are at risk for deconditioning. The algorithm is NOT intended for patients whose primary reason
for admission is mobility related; such patients should be offered physical and occupational
therapy, as appropriate.
Reference: Adapted from tools created by Central DuPage Hospital in Winfield, Illinois, and
subsequently published in Drolet A. Dejuilio P, Harkless S, et al. Move to Improve: the
feasibility of using an early mobility protocol to increase ambulation in the intensive and
intermediate care settings. Phys Ther 2012 Sep 13. [Epub ahead of print]. Tool adapted with
permission of the American Physical Therapy Association. This material is copyrighted, and any
further reproduction or distribution requires written permission from APTA. This is not the final
edited version that appeared in the journal article.
How to use this tool: Nursing assistants or other appropriate hospital staff can follow the
mobility algorithm to initiate mobilization after the treating medical provider orders mobilization
and the patients nurse determines that the patient meets all inclusion criteria and does not have
any exclusion criteria (see below).
This tool can be used in designing a new system, as a training tool for staff, and as an ongoing
reference tool on hospital units. This tool can be modified or a new one created to meet the needs
of your particular setting. If your hospital uses an electronic health record, consult your
hospitals information systems staff about integrating this tool into the electronic health record.

Mobility Algorithm
Adapted from tools created by Central DuPage Hospital in Winfield, Illinois, and published in Drolet A, et al. Phys
Ther 2012 Sep 13. [Epub ahead of print]. Tool adapted with permission of the American Physical Therapy
Association. This material is copyrighted, and any further reproduction or distribution requires written permission
from APTA. This is not the final edited version that appeared in the journal article.

3L: Patient and Family Education
Background: Below are examples of key educational points about fall prevention that can be
handed out to patients and their families.
Reference: Available as a patient education brochure at the Minnesota Hospital Association

Web site:
www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/English_Patient_Education_Brochure.
pdf.
How to use this tool: The information below can be customized for use within your hospital.
When printing your educational brochure, make sure that text is at least 14 points, and make it 16
points if possible; use Times New Roman font or another font that has serifs. We recommend
against printing text over photographs or colors in the background (e.g., black text on a dark
green background) and suggest using sharper contrasting colors to make the text easier to read.
The language should be at no more than a 6th grade reading level to ensure that all patients can
understand the message.
Educators and staff nurses can distribute educational information to patients, but verbal
counseling on fall risk should be performed by someone trained for this task. Consider handing
out educational information to patients and their families when the patient is admitted to your
unit.

Preventing Falls in the Hospital
Know when to ask for help
You will do more and more walking as your health improves. To avoid falling and
hurting yourself, please follow these guidelines.
Wear shoes or nonskid slippers every time you get out of bed.
Call your nurse if you feel dizzy, weak, or lightheaded. Dont get up by
yourself.
Ask for help to go to the bathroom. Make sure the path to the bathroom is clear.
Use only unmoving objects to help steady yourself. Dont use your IV pole, tray
table, wheelchair, or other objects that can move.
Use the handrails in the bathroom and hallway.
If you wear glasses or hearing aids, use them.
Keep important items within reach. This includes your call button or call bell.
Source: Minnesota Hospital Association.

3M: Sample Care Plan
Background: Developing a care plan specific to the needs of each individual patient is
critical. This tool is a sample care plan that gives specific examples of actions that should be
performed to address a patients needs.
Reference: Adapted from National Health Service document Slips, trips, and falls in the
hospital, available at www.nrls.npsa.nhs.uk/resources/?EntryId45=59821. This report is based
on Healey F, Monro A, Cockram A, et al. Using targeted risk factor reduction to prevent falls
in older in-patients: a randomised controlled trial. Age Ageing 2004;33(4):390-5.
How to use this tool: This tool includes examples of interventions that may be considered for
specific fall risk factors. These should be tailored to meet the needs of your patient. The
original care plan was completed for patients with any of the following:
Fall since admission.

Attempt to walk alone unsteady/unsafe.
Patient or relatives anxious about falls.
Your hospital unit may use these factors alone or in combination with additional factors to
trigger use of the care plan. This tool should be used collaboratively by staff nurses with input
from other disciplines (e.g., physician, pharmacist, physical or occupational therapists). If
your hospital uses an electronic health record, consult your hospitals information systems
Individualize the care plan to address the needs of at-risk patients.

Care Plan
GOAL: To reduce likelihood of falls while State action taken below (sample provided):
maintaining dignity and independence
Call. Ensure call bell explained and in reach. Call bell in reach but may forget, will probably
Consider alternatives for patients unable to call her daughters name instead; moved
recall use of call bell, e.g., use brass bell, move within earshot of nurses station.
bed in sight of nurses station.
Eyesight. Ensure eyesight is checked and Glasses broken in fall at home; family has
patient is wearing glasses if needed. Can the ordered replacement and hopes to provide it
patient identify pen/key from bed length away? tomorrow. Has fair distance vision without
If eyesight is too poor to identify objects, ask them. Have suggested that the family order a
the treating medical provider to review. Ensure spare pair too.
glasses/hearing aid are worn or within reach.
Bed and bedrails. Assess the need for bedrails Bedrails not appropriate as this patient can
(refer to policy). If patient is likely to fall from mobilize on her own, even though unsteady,
bed, ensure bed is at the lowest possible height and might be confused enough to climb over.
unless this would reduce mobility or Bed set at right height for safe move from
independence. Consider use of special low sitting to standing.
bed.
Medication. Check for medication associated On temazepam 15 mg qhs for some years; will
with fall risk, such as antidepressants, sleeping discuss with pharmacist.
tablets, sedatives, and antipsychotics. Ask the
pharmacist to review and make
recommendations to treating medical provider
(do not stop abruptly).
Mobility. Determine the patients level of Participating in supervised mobility protocol
mobility and whether actions should be taken with nursing assistant. Currently able to
to improve or maintain mobility. ambulate 50 feet with front wheeled walker
daily.
Interdisciplinary team. Ensure medical staff, Treating physician aware of patients fall risk.
physical therapist, occupational therapist, Physical and occupational therapy referral sent
social worker, and others on the team are on 11/14/11. Fall risk noted on discharge plan.
aware of the patients risk, frequency, nature,
and seriousness of falls (local protocol or
pathway would cover expected actions by team
members, e.g., cognitive evaluation,
osteoporosis check, mobility aid review).
Footwear. Check footwear for secure fit, Patient does not have footwear. Provided with
nonslip sole, no trailing laces. Ask relatives to new slippers from ward stock.
supply safer replacement or supply new
slippers from ward stock. Consider slipper
socks in bed for patients at risk of falling at
night.

GOAL: To reduce likelihood of falls while State action taken below (sample provided):
maintaining dignity and independence
Place. Place patient in most appropriate place Located nearest toilet and within earshot of
on the ward for his or her needs, e.g., close to nurses station.
nurses station, close to toilet, in quietest area
(considering other patients needs as well).
Lighting. Consider lighting best for patient, Will have overhead lamp on low overnight.
e.g., bedside lamp left on overnight, night light
in bathroom.
Toilet. Does the risk of falls appear to be Currently the patient has frequency/urgency;
associated with patients need to use toilet? If being treated for urinary tract infection. Will
so, a routine of frequent toilet visits may help offer toilet every hour while patient is awake.
prevent falls.
Inform. Provide falls education brochure to Patient and daughter have falls education
patient/family, engage them in care plan, find brochure, and care plan has been explained.
out contact wishes in event of fall. Contact wishes entered into chart.

3N: Postfall Assessment, Clinical Review
Background: This protocol explains how to assess and follow injury risk in a patient who has
fallen.
Reference: Adapted from the South Australia Health Fall Prevention Toolkit. Available at:
www.sahealth.sa.gov.au/wps/wcm/connect/5a7adb80464f6640a604fe2e504170d4/Post+fall+ma
nagement+protocol-SaQ-
20110330.pdf?MOD=AJPERES&CACHEID=5a7adb80464f6640a604fe2e504170d4
How to use this tool: Staff nurses and physicians should follow this protocol, in combination
with clinical judgment, with patients who have just fallen. Training on the Glasgow Coma Scale
is available at: www.nursingtimes.net/Binaries/0-4-1/4-1735373.pdf. (Full citation: Jevon P.
Neurological assessment part 4 - Glasgow Coma Scale 2. Nurs Times 2008;104(30):24-5.) This
training includes graphics demonstrating various aspects of the scale.

Postfall Assessment, Clinical Review
Note: There is increased risk of intracranial hemorrhage in patients with advanced age; on anticoagulant and/or
antiplatelet therapy; and known coagulopathy, including those with alcoholism. In addition, there may be late
manifestations of head injury after 24 hours.
Does not hit head Hits head or has unwitnessed fall
Assess immediate danger to all involved. Assess immediate danger to all involved. Assess
Assess circulation, airway, and breathing circulation, airway, and breathing according to
according to your hospitals protocol. your hospitals protocol.
Call for assistance. Activate appropriate Call for assistance. Activate appropriate
emergency response team if required. emergency response team if required.
Do not move the patient until he/she has been Do not move the patient until he/she has been
assessed for safety to be moved. Examine assessed for safety to be moved. Examine cervical
cervical spine and if there is any indication of spine and if there is any indication of injury do not
injury do not move the patient; instead, move the patient; instead, immobilize cervical
immobilize cervical spine, and call treating spine, and call treating medical provider.
medical provider. Assess Glasgow Coma Scale (next page).
Identify all visible injuries and initiate first Identify all visible injuries and initiate first aid; for
aid; for example, cover wounds. example, cover wounds.
Assist patient to move using safe handling Assist patient to move using safe handling
practices. practices.
Proceed to: Proceed to:
Check vital signs (blood pressure, heart rate, Record neurologic observations, including
respiratory rate, oxygen saturation, and Glasgow Coma Scale. Observe for signs indicating
hydration). stroke, change in consciousness, headache,
Clean and dress any wounds. amnesia, or vomiting.
Inform treating medical provider. Get baseline vital signs (blood pressure, heart rate,
Provide analgesia if required and not respiratory rate, oxygen saturation, temperature,
contraindicated. and hydration).
Arrange further tests as indicated, such as Clean and dress any wounds.
blood sugar levels and x rays. Arrange medical review.
Review current care plan and implement Provide analgesia if required and not
additional fall prevention strategies. contraindicated.
Provide fall prevention information (Tool Arrange further tests as indicated, such as blood
3J). sugar levels, x rays, ECG, and CT scan.
Observations: Review current care plan and implement additional
fall prevention strategies.
Continue observations at least every 4 hours Provide fall prevention information (Tool 3J).
for 24 hours or as required.
Observations:
Record vital signs and neurologic observations at
least hourly for 4 hours and then review.
Continue observations at least every 4 hours for 24
hours, then as required.
Notify treating medical provider immediately if
any change in observations.

Important Communications
In the medical record, document the incident, outcome, and initial and ongoing observations, and update
fall risk assessment and care plan.
Notify the treating medical provider at the time of the incident, and schedule an interdisciplinary review
of the patients care.
At handover, inform all clinical team members about the incident, any changes to the care plan, and
possible investigation process.
Notify family in accordance with your hospitals policy.
Glasgow Coma Scale

The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be
in a coma. The total score is the sum of the scores in three categories. For adults, the scores follow:
Activity Score
Eye opening
None 1 = Even to supraorbital pressure
To pain 2 = Pain from sternum/limb/supraorbital pressure
To speech 3 = Nonspecific response, not necessarily to command
Spontaneous 4 = Eyes open, not necessarily aware
Motor response
None 1 = To any pain; limbs remain flaccid
Extension 2 = Shoulder adducted and shoulder and forearm rotated internally
Flexor response 3 = Withdrawal response or assumption of hemiplegic posture
Withdrawal 4 = Arm withdraws to pain, shoulder abducts
Localizes pain 5 = Arm attempts to remove supraorbital/chest pressure
Obeys commands 6 = Follows simple commands
Verbal response
None 1 = No verbalization of any type
Incomprehensible 2 = Moans/groans, no speech
Inappropriate 3 = Intelligible, no sustained sentences
Confused 4 = Converses but confused, disoriented
Oriented 5 = Converses and oriented
TOTAL (315): _______
Reference
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2(7872):81-4.

3O: Postfall Assessment for Root Cause Analysis
Background: A standardized approach to postfall evaluation is key to maintaining the patients
safety and for organizational learning about how to prevent future falls.
Reference: This tool is adapted from a tool developed by Ronald I. Shorr, M.D., M.S. See Shorr
RI, Mion LC, Chandler AM, et al. Improving the capture of fall events in hospitals: combining a
service for evaluating inpatient falls with an incident report system. J Am Geriatr Soc
2008;56(4):701-4.) The Confusion Assessment Method within this tool is adapted from a tool by
Sharon K. Inouye, M.D., M.P.H. (See Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying
confusion. Ann Intern Med 1990;113(12):941-8.)
How to use this tool: The information below can be customized for use within your hospital.
Note that the tool was originally used as part of a dedicated fall evaluation service that was
called to investigate each fall. For details, see the Shorr reference. This tool can be used by staff
nurses and information systems staff.
The tool may be used for the purpose of root cause analysis to prevent future falls in this patient
and in future patients. This assessment should be performed in conjunction with a medical
providers or pharmacists assessment of medications contributing to fall risk (see Tool 3I,
Medication Fall Risk Scale and Evaluation Tools) and a medical providers assessment of
laboratory test results, if appropriate. The Orthostatic Vital Sign Measurement tool (Tool 3F) and
the Delirium Evaluation Bundle (Tool 3J) may be helpful in completing this tool. A separate tool
(Tool 3N, Postfall Assessment, Clinical Review) covers how to assess and follow injury risk
immediately after a patient has fallen.

Postfall Assessment
1. PATIENT/WITNESS DESCRIPTION OF FALL:
1.1. Can you remember anything about your fall?

__Yes __No The patient cant answer reliably
1.2. Did anyone witness the fall?

__Yes, by:
__No or dont know (if no good quality patient or witness description, go to part 2)
1.3. Where did you fall?

__Bathroom __Hall __Room __Other, describe:
1.4. What were you doing at the time of the fall?

__Dont remember
__ Rolled out of bed
__Trying to reach/pick-up something
__Trying to get in/out of bed to go to toilet/commode
__Trying to get in/out of bed for other reason
__Trying to get in/out of chair
__Trying to get on/off bedside commode/toilet
__Trying to use sink, shower, chair, or toilet/commode
__Trying to dress/undress
__Other, describe:
1.5. Why do you think you fell?

__Dont know, remember
__I had a recent lower extremity amputation
__Slipped, tripped
__Got lightheaded, dizzy, or blacked out
__Arms or legs got weak
__Tried to sit, but missed
__I lost my balance
__Got tangled up with IV, tubing, clothes, etc.
__Bed or chair not locked
__Other, describe:

2. BRIEF MENTAL AND PHYSICAL ASSESSMENT
2.1. Short Portable Mental Status Questionnaire
Question Response Error?

What are the date, month, and year?* Date Month Year
What is the day of the week?
What is the name of this place?
What is your phone number?
How old are you?
When were you born?
Who is the current president?
Who was the president before him?
What was your mothers maiden name?
Can you count backward from 20 by 3s?
* A mistake on ANY part of this question should be scored as an error.
Total Errors: _______
SCORING*:
0-2 errors: normal mental functioning
3-4 errors: mild cognitive impairment
5-7 errors: moderate cognitive impairment
8 or more errors: severe cognitive impairment
* One more error is allowed in the scoring if a patient has had a grade school education or less. One less error is
allowed if the patient has had education beyond the high school level.
Section 2.1 adapted with permission from Pfeiffer E. A short portable mental status questionnaire for the assessment
of organic brain deficit in elderly patients. J Am Geriatr. Soc 1975;23(10):433-41. E. Pfeiffer, 1994.

2.2. Confusion Assessment Method
In the 24 hours prior to the fall did this patient: Yes No
CAM 1a. Have an acute change of mental status from baseline?
CAM 1b. Exhibit behavioral fluctuations (come and go)?
CAM 2. Have difficulty focusing attention or appear easily distractible
(for example, have difficulty keeping track of what was said)?
CAM 3. Exhibit disorganized or incoherent thinking such as irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching
from subject to subject?
CAM 4. Are any of the following abnormal levels of consciousness
observed (or reported) in the 24 hours prior to the fall?
Vigilant (hyperalert)
Lethargic (drowsy, easily aroused)
Stupor (difficult to arouse)
Coma (unarousable)
If yes to CAM 1a and 1b and CAM 2 AND either CAM 3 or CAM 4, then delirium is
likely to be present in this patient.
Section 2.2 adapted from Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion. Ann Intern Med
1990;113(12):941-8. Used with permission, Sharon K. Inouye, M.D., M.P.H. 2000, Hospital Elder Life Program.
All rights reserved.
2.3. Severity of injury (check the most severe)
__None (skip to question 2.5)
__Minor (complaint of pain; requires ice, dressing, cleaning of wound, elevating of limb, or
medication)
__Moderate (requires suturing, steri-strips, or splinting)
__Major (requires surgery, casting, traction, neurologic consultation for change in level of
consciousness)
__Possible, at time of this evaluation major injury is suspected but not yet confirmed by tests
__Definite, at time of this evaluation major injury has been confirmed
__Death
2.4. Describe injuries; check all that apply

Injury Yes No Site of Injury
Abrasion/bruise/laceration/hematoma
Bleeding
Pain/difficulty moving extremity
Other:

2.5. Orthostatic blood pressure
Blood Pressure (mm Hg) Heart Rate (beats per minute)
Systolic blood pressure (supine) Heart rate Cant obtain
Diastolic blood pressure (supine) (supine) Refused
Systolic blood pressure (standing) Need for Heart rate Cant obtain
orthostatic (standing) Refused
Diastolic blood pressure Need for
(standing) orthostatic
Systolic blood pressure (sitting)* Heart rate Cant obtain
Diastolic blood pressure (sitting)* (sitting)* Refused
* Sitting measurements are only necessary if standing cannot be obtained.
3. NURSE INTERVIEW (NURSE ASSIGNED TO PATIENT)
3.1. How did you find out that this patient fell?
__I saw the patient fall
__Alarm went off
__Patient/witness called
__Heard noise/found patient on floor
3.2. What was the patient doing at time of fall?

__Dont know
__Rolled out of bed
__Trying to get in/out of chair
__Trying to get in/out of bed to go to the bathroom/commode
__Trying to reach/pick up something
__Trying to get in/out of bed for another reason
__Trying to get on/off toilet/bedside commode (BSC)
__Trying to use the bedside sink, shower, toilet/BSC chair
__Trying to dress/undress
__Other, describe:

3.3. Why do you think the patient fell/lost their balance?
__Dont know
__Catastrophic event (e.g., stroke, arrhythmia NOT orthostatic hypotension)
__Arms or legs got weak
__Got lightheaded, dizzy, or blacked out
__Tried to sit, but missed
__Secondary gain (e.g., seeking attention)
__Related to recent amputation
__Got tangled up in equipment
__Low blood sugar
__Slipped or tripped
__Lost balance
__Medications
__Bed, chair not locked
__Other, describe:
3.4. Prior to the patients fall, what was his/her activity level (ask nurse this question)?
__Up ad lib
__Ambulate with assistance
__Bedrest
__Up in chair with assistance
__Other, describe:
3.5. Prior to fall, identify the ancillary walking aids patient had available in room (check all
that apply):
__None
__Cane
__Walker
__Wheelchair
__Leg prosthesis
__Other

3.6. Prior to fall, were fall prevention measures in place?
Yes No
Falls precautions
Fall alert identifier (door sticker)
Bed alarm: if yes, check those that apply:
Alarm sounded properly
Alarm did not sound properly
Alarm was disconnected
Call light/bell in reach no n/a
Other:
3.7. What CONNECTED IVs/tubes were present at the time of the fall?
Yes No
IV (central line, peripheral)
Bladder catheter
Gastrostomy or other feeding tube
Pneumatic compression stockings
Other:
4. OTHER IMPORTANT INFORMATION NOT COVERED ON THIS FORM
Please record orthostatic blood pressure readings in the patients chart and return this form to the
designated place in the staffing office.

3P: Best Practices Checklist
Background: This tool can be used to monitor your progress on identifying best practices in fall
prevention for your hospital or hospital units.
How to use this tool: Complete the checklist. This tool should be filled out by the
Implementation Team leader (or individual designated by the leader).
Best Practices Checklist

Practice Date Completed
Identify a set of best practices
Create a clinical pathway
Identify key elements of a fall risk factor assessment
Choose a tool for assessing risk factors
Explore approaches to documenting and reporting results of fall risk factor
assessment
Develop fall prevention care plan based on identified risk factors
Identify approaches to documenting and communicating care plan
Develop system linking changes in fall risk factors to changes in care plan
Ensure all levels of staff are aware of care plan
Develop system linking care planning to actual interventions
Choose or develop postfall assessment protocol
Customize the set of practices for specific work units

4A: Assigning Responsibilities for Using Best Practices
Background: This tool can be used to determine who will be responsible for each task identified
in your set of best practices for preventing falls. One way to generate interest and buy-in from
the staff is to ask them to self-assign their responsibilities from a prioritized list of tasks that need
to be accomplished.
How to use this tool: Complete the table by entering the different best practices and the specific
individuals who will be responsible for completing each task. This tool should be filled out by
the Implementation Team leader in collaboration with the other team members.
Use this tool to assign and clarify the roles and responsibilities of each staff member. Types of
staff and the types of responsibilities they might take on are summarized in Tool 4B, Staff
Roles.
What practices will we use? Who will be responsible?

Example: Example:
Perform comprehensive fall risk RN
assessment on admission, daily, or if
condition deteriorates.

4B: Staff Roles
Background: This table gives an example of how responsibilities may be assigned among
different staff members on the Unit Team and hospital personnel whose work brings them to the
unit or includes interactions with the unit.
How to use this tool: The unit manager can use this tool to help assign specific individuals or
groups to each task in Tool 4A, Assigning Responsibilities for Using Best Practices.
Staff Roles
RN Conducts or supervises accurate assessment and documentation of
assessment of fall risk factors on admission, daily, and if condition
deteriorates (or according to facility policy).
Documents care plan tied to identified risk:
o Mental status.
o Continence.
o Mobility level.
o Environmental risks (e.g., hooked up to IV).
Performs or supervises performance of care plan procedures or
treatments:
o Close observation of delirious patients.
o Toileting schedule.
o Use of assistive devices.
o Maintenance of clutter-free environment.
Files incident report for new falls and carries out postfall assessment.
Educates patient/family about fall risk factors.
LPN Conducts accurate assessment and documents assessment of fall risk
factors on admission, daily, and if condition deteriorates (or according
to facility policy).
Documents care plan tied to identified risk:
o Mental status.
o Continence.
o Mobility level.
o Environmental risks (e.g., hooked up to IV).
Performs or supervises performance of care plan procedures or
treatments:
o Close observation of delirious patients.
o Toileting schedule.
o Use of assistive devices.
o Maintenance of clutter-free environment.
Collaborates with other staff to ensure timely and accurate reporting of
any falls and completion of postfall assessment.

Staff Roles
CNA Reports any new fall risks to nurse.
Keeps environment around bed clutter free.
Offers assistance with toileting for patients with frequent toileting
needs.
Keeps assistive devices within easy reach of patient.
Treating Reviews needs for specific types of rehabilitation therapy and orders
medical such therapy, if appropriate.
provider (e.g., Writes orders for activity level.
physician, Reviews medications for fall risk.
nurse
practitioner,
physician
assistant)
Physical Assesses patients function and mobility levels according to scheduled
and/or protocol (e.g., after orthopedic procedures) or upon consultation.
occupational Determines need for assistive devices and exercise program according
therapist to scheduled protocol (e.g., in rehabilitation unit) or upon consultation.
Educates patient and family on safety with transfers and ambulation.
Pharmacist Reviews medication lists of patients at high risk based on medication
profile.
Discusses medications that may increase fall risk with physician using
standardized approach (e.g., note in chart, rounds with hospitalist).
Environmental Responds to reports of fall hazards (e.g., spills).
services staff Keeps rooms and hallways free of clutter.
Dietitian Monitors patients weight and nutritional status to avoid unintentional
weight loss and loss of muscle mass.
Provides tube feed regimens that maximize mobility (e.g., choosing
bolus rather than continuous tube feeding where appropriate).
Patient Works with nurse to provide appropriate educational materials and
educator teaching to patients at risk for falls and their families.
Facilities Participates in regularly scheduled environmental rounds to identify
engineer equipment in need of repair.
Responds to repair requests submitted by unit staff.
Information For units with electronic health records:
technology Develops or refines documentation systems for fall risk assessment and
support care planning.
personnel Develops or refines computerized order sets (e.g., mobility protocol).
Implements computerized alerts for medications that present high risk
for falls, where appropriate.

4C: Assessing Staff Education and Training
Background: The purpose of this tool is to assess current staff education practices and to
facilitate the integration of new knowledge on fall prevention into existing or new practices.
Reference: Adapted from Facility Assessment Checklist developed by Quality Partners of

Rhode Island. Available at: www.healthinsight.org/Internal/assets/Nursing%20Home/PRU%20-
%20Facility%20Assessment%20Checklist.pdf.
How to use this tool: Complete the form by checking the response that best describes your
hospital. This tool should be filled out by the Implementation Team leader or designee in
collaboration with the other team members.
This tool can be used to identify areas for improvement and develop educational programs where
they are missing.

Facility Assessment
Date:
A. Does your hospital have initial and ongoing education on fall prevention and management for
both nursing and nonnursing staff?
__ No. If no, this is an area for improvement.
__ This is an area we are working on.
__ Yes.
B. Does your facilitys education program for fall prevention and management include the
following components?
Person
Yes No Responsible Comments
Are new staff assessed for their need for
education on fall prevention and
management?
Are current staff provided with ongoing
education on the principles of fall
prevention and management?
Does education of staff provide discipline-
specific education for fall prevention and
management?
Is there a designated clinical expert
available at the facility to answer
questions from all staff about fall
prevention and management?
Is the education provided at the
appropriate level for the learner (e.g.,
CNA vs. RN?)
Does the education provided address risk
factor assessment tools and procedures?
Does the education include staff training
on documentation methods related to falls
(e.g., circumstances of fall if applicable,
risk factors for falls, how those risk
factors have been addressed)?
C. In which areas of knowledge does the assessment suggest staff need more education?

4D: Implementing Best Practices Checklist
Background: This tool can be used to monitor your progress on implementing best practices.
should complete the checklist.
Implementing best practices checklist

Task Date
Completed
Roles and Responsibilities of Staff
Assign specific roles and responsibilities to:
Members of the Unit Team
Unit Champion
Organizing the Prevention Work
Identify paths of ongoing communication and reporting
Develop mechanisms to address accountability
Identify strategies for building new practices into daily routine
Refine preliminary implementation plan
Ensure support from key stakeholders
Initiate plan to pilot test new practices
Establish strategy for engaging staff
Create education plans to help staff learn new practices

5A: Information To Include in Incident Reports
Background: The purpose of this tool is to audit incident reports of falls to see if the reports
provide adequate information for root cause analysis. Alternatively, the information below may
be used in conjunction with Tool 3O, Postfall Assessment for Root Cause Analysis to develop
a template to be filled out when reporting a fall.
Reference: Adapted from National Health Service publication Slips, Trips, and Falls in the
Hospital, available at www.nrls.npsa.nhs.uk/resources/?EntryId45=59821.
How to use this tool: Review your last 10 incident reports for falls and see whether the
information below is captured in the report. This tool should be used by the quality improvement
manager. Information systems staff may also use this tool to develop or update electronic
templates for submitting incident reports.
Use this tool to identify areas for improvement and develop educational programs where there
are gaps.

Information To Include in Incident Reports
Examples of Information Reason To Collect This Information
Reporting Witnessed/not Make a clear distinction between what was seen
factors witnessed or heard and the patients account of what
happened.
Outcome of When patients are reported as having x rays or
investigations other investigations after a fall, the results of the
recorded x ray or other investigation should be included in
the report.
Type of injury Be specific, e.g., fractured tibia, not broken
leg.
Environmental Buzzer/bell available Highlight whether there is an issue about
factors within reach before accessing call bells.
fall
If a fall from bed, Help assess how bedrail use is affecting falls or
whether bedrails were injury.
in use
Floor wet/dry/talcum Reflect on cleaning regimen and need for nonslip
powder surfaces.
Footwear If problems with missing or unsuitable footwear
are highlighted, organizations could develop
systems for providing alternatives.
Walking aid in use/in It may highlight bedside storage issues or access
reach to walking aids for patients admitted in the
evenings or on the weekend.
Patient factors Mental state Identify those patients most vulnerable to falls
because of sedation, dementia, or delirium.
First fall this Balance resources between preventing initial
admission or repeat falls and secondary prevention.
fall
Days since admission Ensure timescales for assessing and preventing
falls are tailored to when falls are most likely to
occur.
Medication affecting Sedative and psychotropic medication, or
risk of falls medication with drowsiness as a side effect, may
contribute to falls.

5B: Assessing Fall Prevention Care Processes
Background: This sample protocol illustrates how to evaluate whether fall prevention care
processes are occurring as they should be.
Reference: Adapted with permission from: Royal College of Physicians Implementing

FallSafe: Care bundles to reduce patient falls. London, UK: Royal College of Physicians;
2012. Available at: www.rcplondon.ac.uk/resources/falls-prevention-resources.
How to use this tool: Use this form to observe the patient at bedside and check the notes of
20 patients on your unit every month (ideally the same date each month). To select patients:
If you are a small unit, collect it from the first 20 patients who come first in handoffs.
If your unit has two teams, take the first 10 patients from each team.
And so on if you have three teams, etc.
The assessment requires different types of information. Depending on your hospitals record
system and workflow, the information may be found in multiple locations. Make sure the
people completing the form know where to find the information, which may require
modifying the form to include explicit directions or cues.
Observations at the bedside should occur at the time of day when most patients who are well
enough would be out of bed. If your hospital uses hourly rounding logs, these can also be
checked for completeness during the observations. For the chart review, check the medication
administration record (MAR) and any notes easily accessible on the unit, including nursing
notes, medical notes, physical therapy notes, and occupational therapy notes. The bedside
observations and the chart review can be completed separately but should be done on the
same day.
This form should be completed by the unit manager or unit champions. This tool should be
used to determine whether your hospital unit is carrying out its fall prevention care processes
according to plan. It can be modified according to the needs of your specific hospital or unit
by adding/deleting rows to customize the processes you want to monitor. Your hospital or
unit might use this as an initial screen for assessing progress and then use the results to
identify specific components for additional evaluation.

Sample of 20 patients (or all patients if ward has fewer than 20 patients)
Example 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Use to track patient Totals (yes out
names/initials/bed number/room of total plus
NM
YH
HK
HY
AB
TY
YT
KL
GT
DE
FH
MJ
UP
FR
FR
LT
LT
TT
ST
ES
number if you need to N/A)
All 20 patients: If small ward with fewer than 20 patients, write total here:
Observe: call bell in sight & Y N n/a Y Y Y Y Y n/a Y Y Y Y N Y Y n/a N Y Y 14/17 + 3 n/a
reach?
Observe: safe footwear on feet? Y Y Y Y Y Y Y Y N Y Y Y Y N Y Y n/a n/a N N 14/18 +2 n/a
Observe: room free of clutter? Y Y Y Y N Y Y Y Y Y Y N Y Y N N Y Y Y Y 16/20
Medication administration record: N N N N N N N N N N Y N N N N N N N Y N 2/20

given night sedation last night?
Chart: asked about history of Y Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y 18/20
falls?
For any of the 20 pts age 70+: Number of patients AGE 70+: 13
Chart: cognitive screen? Y N - - - - - Y n/a Y Y Y Y N Y - - N Y Y 9/12 + 1 n/a
For any of the 20 patients who are Number of higher risk patients: 8
higher risk*:
Chart: full medication review Y Y - - - - - - - Y Y N Y Y - - - - Y - 7/8
requested?
* In some wards all patients are counted as high risk, for other wards only some. Follow your local policy.
2012, Royal College of Physicians. Adapted with permission.

*** Sample of 20 patients (or all patients if ward has fewer than 20 patients). Remember not documented=not done ***
Filled out by: WARD:

1 2 3 4 5 6 7 8
9 10 11 12 13 14 15 16 17 18 19 20
DATE: TOTALS
Use to track patient (YES out of
names/initials/bed number/room total plus
number if you need to N/A)
All 20 patients: If small ward with fewer than 20 patients, write total here:
Observe: call bell in sight &
reach?
Observe: safe footwear on feet?
Observe: room free of clutter?
Medication administration
record: given night sedation last
night?
Chart: asked about history of
falls?
For any of the 20 pts age 70+: Number of patients AGE 70+:
Chart: cognitive screen?
For any of the 20 patients who Number of higher risk patients:
are higher risk*:
Chart: full medication review
requested?
* In some wards all patients are counted as high risk, for other wards only some. Follow your local policy.
2012, Royal College of Physicians. Adapted with permission.

5C: Measuring Progress Checklist
Background: This tool can be used to monitor progress on your fall prevention efforts.
should complete the checklist.
Measuring Progress
Measuring fall rates
Staff know definition of fall and definition of injurious fall
Management culture rewards full reporting of falls
Fall rates (e.g., falls per 1,000 occupied bed days) are calculated
Fall rates are monitored at least quarterly, preferably monthly
Information on rates is disseminated to key stakeholders and staff
Root cause analysis is conducted for each fall with at least moderate level of
injury
Measuring key processes of care
Fall risk factor assessment is performed within 24 hours of admission
Care plan addressing every deficit on fall risk factor assessment has been
developed and is being implemented

6A: Sustainability Tool
Background: This tool can be used to identify sustainability issues in planning and
implementing your fall prevention efforts.
Reference: Adapted with permission from: Edwards JC, Feldman PH, Sangl J, et
al.Sustainability of partnership projects: a conceptual framework and checklist. Jt Comm J Qual
Patient Saf 2007;33(12 Suppl):37-47.
should complete this checklist.
Use this tool to ensure you have appropriate resources and strategies in place to sustain fall
prevention efforts.

Elements of Sustainability Notes
Identity (Goals)
Is guiding vision clearly specified?
Is change goal focused (not too encompassing) and actionable?
Is sustainability goal clarified (i.e., what will be sustained?) and at
what level is this goal?
Specific process or outcome
General capacity to improve on more than one outcome or
process
Partnership itself
Problem solving: If vision and goals are not clearly specified, focused,
and actionable, what strategies will be adopted to address this issue?
Infrastructure
Human resources
Are the internal/external human resources in place to sustain the
effort going forward (describee.g., team, senior leadership,
champion, opinion leader)?
Are external supports in place to sustain the effort going forward
(describee.g., mentors, advisory group, professional
associations, community advocates)?
Technical resources
Are materials developed and accessible if sought?
Are there listservs, meetings, and other mechanisms to promote
ongoing communication?
Are training and technical support available to develop and
maintain necessary skills?
Are information systems in place to support the effort going
forward?
Financial resources
Is funding adequate for the time period required to achieve the
change goal?
Is funding source stable for the time period needed to
accomplish guiding vision?
Problem solving: If key elements are lacking, has a strategy been
developed to address this issue?
Incentives
Is project perceived to add value within the organization (i.e., people
can see something in it for them)?
Can value be measured quantitatively (i.e., decrease in injurious fall rate
or maintenance of low injurious fall rate)?
Are other intangible values/incentives perceived (e.g., improved
reputation, pride, sense of accomplishment)? Describe.

Elements of Sustainability Notes
Is the project perceived as having disincentives? Describe.
Problem solving: If positive incentives are inadequate or disincentives
are identified, have strategies been proposed to address this issue?
Incremental Opportunities for Participation
Can the project goals be best achieved with varied levels and types of
participation?
If yes, then continue to next two questions.
Are there opportunities for varied geographic participation (e.g., among
units within a hospital; among hospitals within a consortium;
participation in regional vs. national initiative)?
If yes, what types of varied geographic participation
opportunities are available?
Is the geographic scale workable?
Are varied roles for participation in the project provided?
If yes, what varied roles for participation are provided?
Observer role
Technical assistance role
Data collection role (e.g., review charts or incident reports)
Advisor or consultant role
Implementer role
Changing role throughout the project
Can pick and choose among offered activities
Can opt out and then opt back in later
Other
Problem solving: If goals can be achieved with varied levels and types
of participation but no provision has been made for participation in
different ways, what strategies can be used to address this issue?
Integration
Are change goals aligned with strategic goals of participating entities
(macro level)?
Are change goals integrated with other performance measures and
reward systems of participating entities (macro level)?
Are change goals integrated with existing programs,
policies/procedures, and information systems of participating entities
(micro level)?
Problem solving: If change goals are not aligned and integrated with the
strategic goals, performance measures, reward systems, programs,
policies/ procedures, and information systems of participating entities,
what strategies can be used to address this issue?

Appendix: Bibliography of Studies Implementing Fall Prevention Practices
The recommendations presented in this toolkit are based on a review of the evidence in the scientific literature, consensus
recommendations, and expert input. To provide additional guidance for your fall prevention program, we have included references to
programs that implemented many of the strategies presented in the toolkit within U.S. acute care hospitals.
For a full evidence review of the literature, see Hempel S, Newberry S, Wang Z, et. al. Review of the evidence on falls prevention in
hospitals. RAND Working Paper WR-907-AHRQ. Santa Monica, CA: RAND Corporation; 2012. Available at:
www.rand.org/pubs/working_papers/WR907.html.
Toolkit Section Studies Implementing Fall Prevention Practices

1. Are you ready for this change? Nine programs implemented strategies to gain leadership support.1-9
One program addressed culture change.9
One program incorporated fall prevention into the organizational strategic plan.7
2.1. How can you set up the Sixteen programs formed interdisciplinary teams.5,7-21 Two additional programs
implementation team for success? formed other implementation teams.3,22
One program addressed other strategies to help set up the Implementation Team for
success.18
2.2. What needs to change and how do Seven programs followed systematic approaches to analysis and implementation such
you need to redesign it? as a Continuous Quality Improvement model,5,9 Plan-Do-Program-Act,18,23 Plan-Do-
Check-Act,13,19 or Rapid Improvement Event.24
One program assessed current staff knowledge of fall prevention.25
2.3. How should goals and plans for One program developed an implementation plan.13
change be developed?
3.2. What are universal fall precautions Ten programs implemented scheduled rounding to address patient needs.7,10,25-32
and how should they be implemented? Nine programs conducted regular environmental safety inspections or other strategies
to make the environment safer.7,10,21,28,33-37
Fourteen programs implemented other universal fall precaution
strategies.6,10,12,13,19,22,24,27,35,36,38-41
Appendix 185
3.3. What is a standardized assessment Based on the evidence review, the Morse Falls Scale and STRATIFY are the most
of risk factors for falls, and how should thoroughly studied fall risk assessment tools. Both scales have established reliability
this assessment be conducted? and validity, but research has shown that the scores from these tools may not predict
falls any better than a clinicians judgment.
Fall risk assessments were implemented in 38 programs.1,3,6-9,11-22,24 28,30,32,33,35-46 Five
programs used the Morse Fall Scale.13,26,28,42,45 One program used a medication fall
risk assessment.28
3.4. How should identified risk factors Thirty-five programs implemented structured care plans for fall
be used for fall prevention care prevention.1-3,5-15,20-22,25,27,30,32,33,35-42,46-50
planning? Five programs addressed medication review,4,16,18,26,46 four programs included
physical therapy review or mobility,4,10,16,51 and two programs implemented strategies
to address patients with altered mental status or delirium prevention.4,10
One program used specially configured rooms equipped with safety equipment.34
Twenty-four programs addressed patient and family education through handouts or
posters in patient rooms.6,7,9,12,14-20,22,24,25,27,28,31,32,35,37-40,42
Programs also discussed strategies for documentation and communication of care
planning. Nineteen programs addressed fall risk documentation and
communication.1,7,10,11,13-15,17-19,22,24,25,35,38,39,46-48
Eight programs had care plans disseminated at change of shift reports.3,11,19-21,32,47
Twenty-six programs used other strategies to communicate the care
plan.1,5-8,10-12,14,15,17,20-23,25,27,30,32,33,39-42,47,48
One program implemented postfall safety huddles to improve communication between
staff, patients, and families.32
3.5. How should you assess and Thirteen programs conducted postfall reviews.2,9,11,18-22,24,27,32,33,52
manage patients after a fall?
Appendix 186
4.1. What roles and responsibilities Three programs implemented strategies to optimize roles and responsibilities to
will staff have in preventing falls? provide the best care possible.3,23,53
Two programs used Unit Champions during the implementation process.11,18
One program discussed enhancing communication and responding to patients needs
in a timely fashion.53
Six programs implemented strategies to integrate fall prevention into ongoing work
processes.10,11,13,36,48,54
Six programs built documentation of fall risk and/or care planning into their electronic
documentation systems.10,18,32,35,48,54 Three additional programs implemented
strategies to streamline documentation.3,13,36
4.3. How do you put the new practices Seven programs implemented strategies to promote unit-level buy-in.7,11,13,18,22,32,42
into operation? Six programs implemented strategies for ongoing monitoring of implementation
progress or assessed barriers to implementation.7,13-15,26,27
Thirteen programs piloted the program, tested new strategies in select areas of the
hospital, or phased in interventions.6-8,12,15,17-19,22,24,32,35,45
One program used the development of a policy and procedures to facilitate
implementation.46
Two programs implemented strategies to get staff engaged and excited about fall
prevention.11,39
Forty-one programs used staff education or other strategies to help staff learn new
practices.1-7,9-15,18-25,27-32,35,37,38,40,41,43,45-49,52,55
5.1. How do you measure fall rates? Thirteen programs monitored and disseminated data on falls.2,5,7-9,13,19,20,25,28,39,41,47
One program documented falls in incident reports.41
Five programs conducted root cause analysis of falls to help identify ways to improve
care.2,9,11,12,24
5.2. How do you measure fall Eighteen programs measured and monitored adherence to key processes of
prevention practices? care.1,2,9,13,15,18,24,25,28,29,31,38,39,41,42,45,47,51
One program assessed care planning to ensure that it addressed each deficit on the fall
risk factor assessment.27
One program conducted medical record audits to determine compliance with
recommended interventions and postfall documentation.24
Appendix 187
6. How do you sustain an effective fall One program evaluated policy twice yearly to see if modifications were needed.46
prevention program? Seven programs implemented ongoing awareness efforts and project updates to keep
staff engaged.8,9,14,25,30,37,41
Five programs incorporated fall prevention training into staff orientation.4,7,25,35,39
Appendix 188
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Uploaded by

Uploaded by

Preventing Falls in

Agency for Healthcare Research and Quality

Contract No. HHSA290201000017I TO #1

AHRQ Publication No. 13-0015-EF

Boston University School of Public Health

Kathryn Pelczarski, B.S.

Section 2 How will you manage change?

Who should use the

Section 3 Which fall prevention practices do you want to use?

Tool 3H, Morse Fall Scale for Identifying Fall Risk

Tool 3I, Medication Fall Risk Scale and Evaluation

Tool 3L, Patient and Family Education

Tool 3M, Sample Care Plan

Who should use the

Section 6 How do you sustain an effective fall prevention program?

We thank them for their valuable contributions.

The Challenges of Fall Prevention

Implementation Guide Organized To Direct Hospitals Through the Change

o Are you ready for this change?

Sections of the Guide

Adaptation of the Guide to Your Organization

Improvement as Puzzle Pieces

Action and Resource Symbols

Denotes action steps

Denotes a tool for this action in Tools and Resources

Denotes a linked tool or other resource for this action

Denotes practice insights

Includes added commentary or examples drawn from

Denotes additional background material for those

Each question below will help you and your organization

Do organizational members understand why change

Organizational Readiness for Change: Locally Relevant Considerations

Some hospitals may experience significant turnover in senior leadership

This section of guide addresses these types of issues.

1.1. Do organizational members understand why change is needed?

Section 1: Assess Readiness 6

Has your facility experienced a significant increase in fall rates?

Did you know?

Section 1: Assess Readiness 7

Identify the reasons for having a fall prevention program in your

1.2. Is there urgency to change?

Section 1: Assess Readiness 8

Consider using the introductory slide presentation developed by ECRI

1.3. Does senior administrative leadership support this program?

Section 1: Assess Readiness 9

Many hospitals have a strong emphasis on quality improvement, with an improvement

Hospital Leadership Team

A typical hospital includes these three leadership groups:

Top-level administration (e.g., chief executive officer, chief financial

Hospitals vary with how they involve these groups in decisionmaking.

The influence of top management, board, and physician leadership on hospital

Section 1: Assess Readiness 10

1.4. Who will take ownership of this effort?

Assess your organization to identify who the potential advocates of fall

Section 1: Assess Readiness 11

1.5. What resources are needed?

1.6. What if you are not ready for full-scale change?

Section 1: Assess Readiness 12

1.7. Checklist for assessing readiness for change

Section 1: Assess Readiness 13

Your timeline should balance the need to act systematically

In section 1.4, you identified members of the organization

How can you set up the Implementation Team for success?

What needs to change and how do you need to redesign it?

How should goals and plans for change be developed?

How do you bring staff into the process?

Section 2: Manage Change 14

In trying to manage change at the organizational level, your hospital may

The need for an effective fall prevention program, an interdisciplinary

o Many hospitals have nurse-driven fall prevention committees and

These types of challenges are addressed in this section.

A strong link to hospital leadership,

Section 2: Manage Change 15

How do we determine members of the Implementation Team?

2.1.1. Who should serve on the Implementation Team?

Section 2: Manage Change 16

This Institute for Healthcare Improvement Web site (Science of Improvement:

How often to meet (e.g., monthly).