A Toolkit for Improving Quality of Care
Each year, somewhere between 700,000 and 1,000,000 people in the United States fall in the hospital. 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. Fall prevention involves managing a patient's underlying fall risk factors and optimizing the hospital's physical design and environment. This toolkit focuses on overcoming the challenges associated with developing, implementing, and sustaining a fall prevention program.
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Healthcare Research and Quality
University School of Public Health
No. HHSA290201000017I TO #1
The Problem of Falls
The Challenges of Fall Prevention
Toolkit Designed for Multiple
Implementation Guide Organized To
Direct Hospitals Through the Change Process
Sections of the Guide
Adaptation of the Guide to Your
Improvement as Puzzle Pieces
1. Are you ready for this change?
1.1. Do organizational members
understand why change is needed
1.2. Is there urgency to change?
1.3. Does senior administrative
leadership support this program?
1.4. Who will take ownership of this
1.5. What kinds of resources are
1.6. What if you are not ready for
1.7. Checklist for assessing
readiness for change
2. How will you manage change?
2.1. How can you set up the
Implementation Team for success?
2.2. What needs to change and how do
you need to redesign it?
2.3. How should goals and plans for
change be developed?
2.4. Checklist for managing change
3. Which fall prevention practices do
you want to use?
3.1. Which fall prevention practices
should you use?
3.2. What are universal fall
precautions and how should they be implemented?
3.3. What is a standardized
assessment of risk factors for falls, and how should this assessment be
3.4. How should identified risk
factors be used for fall prevention care planning?
3.5. How should you assess and manage
patients after a fall?
3.6. How can your hospital
incorporate these practices into a fall prevention program?
3.7. What additional resources are
available to identify best practices for fall prevention?
3.8. Checklist for best practices
4. How do you implement the fall
prevention program in your organization?
4.1. What roles and responsibilities
will staff have in preventing falls?
4.2. What fall prevention practices
go beyond the unit?
4.3. How do you put the new practices
4.4. Checklist for implementing best
5. How do you measure fall rates and
fall prevention practices?
5.1. How do you measure fall and
fall-related injury rates?
5.2. How do you measure fall
5.3. Checklist for measuring progress
6. How do you sustain an effective
fall prevention program?
6.1. Who will be responsible for
sustaining active fall prevention efforts on an ongoing basis?
6.2. How will you continue to monitor
fall rates and fall prevention care processes?
6.3. What types of ongoing
organizational support do you need to keep the new practices in place?
6.4. How can you reinforce the
7. Tools and Resources
Appendix: Bibliography of Studies
Implementing Fall Prevention Practices
Ganz, MD, PhD, VA Greater Los Angeles Healthcare System, University of
California at Los Angeles, and RAND Corporation
Huang, MPH, RAND Corporation
Saliba, MD, MPH, VA Greater Los Angeles Healthcare System, UCLA/JH Borun
Center for Gerontological Research, and RAND Corporation
Victoria Shier, MPA, RAND Corporation
University School of Public Health
Berlowitz, MD, MPH, Bedford VA Hospital and Boston University School of
Carol VanDeusen Lukas, EdD, VA Boston Healthcare System
and Boston University School of Public Health
Schoelles, MD, SM
Wallace, MSN, BSN
Patricia Neumann, RN, MS
The opinions expressed in this document are those of the
authors and do not reflect the official position of AHRQ or the U.S. Department
of Health and Human Services.
Publication No. 13-0015-EF
Current as of January 2013
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. AHRQ
Publication No. 13-0015-EF, January 2013. Rockville, MD, Agency for Healthcare Research and Quality. http://www.ahrq.gov/research/ltc/fallpxtoolkit/index.html