5. How do you measure fall rates and fall prevention practices?
A basic principle of quality measurement is: If you can't
measure it, you can't 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:
section will discuss these types of issues.
Revising incident reports to include more specific fields for
contributing factors to falls (e.g., high-risk medications, which
Finding mechanisms to communicate fall incident report information
to the Implementation Team.
Using process metrics to measure the adherence to fall
Spreading lessons learned from postfall safety huddles and root
cause analyses from one hospital unit to another.
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5.1. How do you measure fall and fall-related
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
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
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 wouldn't 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
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:
- None—patient 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.
"Minor—resulted in application of a dressing, ice, cleaning
of a wound, limb elevation, topical medication, bruise or abrasion.
Moderate—resulted in suturing, application of
steri-strips/skin glue, splinting or muscle/joint strain.
Major—resulted 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.
Death—the 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
- 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:
Generate an incident report for every fall that occurs. The incident
report will need to contain, at a minimum:
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).
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.
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.
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.
Let's 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
First, count the number of falls that occurred during the month of April
from your incident reporting system. Let's 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. Let's 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
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). Don't overreact to any individual month's
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
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:
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 .
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
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:
information, see Lake ET, Shang J, Klaus S, et al. Patient falls: association
with hospital magnet status and nursing unit staffing. Res Nurs Health
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.
||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/ANAPeriodicals/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 patient's 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 hospital's 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 (go to section 3.4.4 for
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 [Plugin Software Help]
www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/post-fall-huddle-documentation.pdf [Plugin Software Help]
use these forms or create your own, based on your hospital's 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.
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, go to: www.patientsafety.gov/CogAids/RCA/index.html#page=page-1.
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 unit's 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
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 hospital's 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.
5.1.8. How can you improve the quality of the data being collected for fall
To improve data quality, you will need to improve staff reporting
of falls, particularly the circumstances surrounding the fall (go to 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.
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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
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
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
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,
physician's 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 patient's 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 (go to Tool 3L)?
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 patient's risk factors. Ensure that the care plans address all
areas of risk.
| Sample Assessment of Care Planning Performance
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.
For each patient, determine the patient's identified risk factors.
Identify the fall prevention components of care plans prepared shortly
Determine whether each patient's unique fall risk factors are
addressed in the care plans.
Calculate the percentage of the assessment patient's 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
5.2.4. What data sources should be used in measuring fall prevention
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 patient's 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
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.
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
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5.3. Checklist for measuring progress
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