3. Which fall prevention practices do you want to
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
Which fall prevention practices should you use?
Which universal fall precautions should be applied throughout the
How should a standardized assessment of fall risk factors be
- 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
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
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
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 patient's fall risks get to the right member of the team at
the right time?
Fall prevention needs to becustomized. Each
patient has a different set of fall risk factors, so care must thoughtfully
address each patient's unique needs.
Return to Contents
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 (go to 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 hospital's 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 patient's
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 patient's
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 (go to section 3.2) coupled with attempts to address the
patient's risk factors (go to 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 (go to section
3.5), coupled with injury prevention measures in the case of recurrence
(go to section 3.4), are key for these
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 (go to section 3.2).
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
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
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
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
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.
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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 hospital's
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 patient's 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 (go to section 3.7) is provided
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
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
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
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
patient's 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 patient's
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.; go to 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 nurse's 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 P's" or "5 P's," it represents a set
of items to mentally review when rounding on the patient. For example, the 5
P's could be:
Pain: Assess the patient's 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 patient's essential needs (call
light, phone, reading material, toileting equipment, etc.) are within easy
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 patient's room.
Hourly rounding has been carried out in different ways by
different hospitals. Despite its seeming simplicity, it requires careful
planning to implement. Go to section 4 for strategies
on implementing new care processes at your hospital.
||To read more about the evidence that supports hourly
Halm MA. Hourly rounds: what does the evidence indicate? Am J
Crit Care 2009;18:581-4.
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.
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:
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_Guidelines.
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
||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
||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
3.2.4. How should universal fall precautions be
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
patient's 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
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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
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
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.
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 (go to 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
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
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 patient's 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 patient's 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 hospital's 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.
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 unit's 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 (go to Tool 3I, "Medication Fall Risk Score 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 patient's 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.
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 patient's 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.
specific patient situation, ask yourself and your team:
How often should the assessment of fall risk factors be done on
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.
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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 patient's 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 patient's 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 planning's specific purpose is to identify specific care practices
that will be implemented so that the patient is less likely to fall during the
Care planning accounts for multiple factors that pertain to
the patient's 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
patient's response to the interventions as well as any changes in his or her
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 patient's 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 patient's 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
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 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
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
||Safety Zones:A Strategy for Supervising Cognitively
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.
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 hospital's
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, 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 Parkinson's 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.
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,
go to Tool 3B).
Patients with visual impairment should have corrective
lenses easily within reach.
Patients on high-risk medications (go to Tool 3I, "Medication Fall Risk Score 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
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 (go to Tool 3F). Finally, the patient and patient's
family should be alerted and educated about fall risk and steps to prevent
falls when the patient is taking these medications.
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.
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
patient's physical environment should be reviewed to reduce the risk of injury
(e.g., making sure the patient's bed is set low when the patient is resting in
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 patient's
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 (go to 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,
Documenting patient's refusal.
Trying to discover the basis for the patient's refusal.
Presenting a rationale for why the intervention is important.
Designing and offering an alternative plan and documenting the
patient's response, including the patient's comprehension of all options
presented. This alternative strategy needs to be described in the care plan and
documented in the patient's medical record.
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
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 patient's risks.
Consider the following strategies to enhance awareness of
fall risk factors and appropriate documentation:
Incorporating fall risk factors and interventions in daily
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 patient's 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 patient's
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
||The following article describes an effort to communicate a
patient's 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.
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
Patients demonstrating particularly high risk behaviors can
be discussed as part of the unit's 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.
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. Go to the resource box titled "One Hospital's Approach to
Maintaining Patient Mobility" in section 6.4 for
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 patient's 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
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 staff's
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 provider's
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
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.
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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
patient's 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
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
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, go to section
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 patient's
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 hospital's specific needs.
Documenting and communicating the clinical review are
critical to the patient's 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 patient's root cause analysis is
complete, a safety huddle (go to 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
(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 patient's 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 hospital's incident reporting system,
go to section 5.
3.5.5. What are challenges to performing the clinical review and root cause
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 patient's 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 (go to 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:
version of the tool used in this study is presented as Tool 3O.
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.
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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 (go to 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
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.
- 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.
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.
Patients are 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.
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 patient's
medication profile within 24 hours of admission.
Some patients are placed in
safety zone (semiprivate rooms with a patient care observer on duty; go to 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.
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'
Nurses and physicians work
together to evaluate medications that interfere with neurologic exam and
alter patient's 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.
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.
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additional resources are available to identify best practices for fall
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.
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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.
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
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.
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 .
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