Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

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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 implementation team for success?	Sixteen programs formed interdisciplinary teams.^5,7-21 Two additional programs 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 you need to redesign it?	Seven programs followed systematic approaches to analysis and implementation such 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 change be developed?	One program developed an implementation plan.¹³
3.2. What are universal fall precautions and how should they be implemented?	Ten programs implemented scheduled rounding to address patient needs.^7,10,25-32 Nine programs conducted regular environmental safety inspections or other strategies to make the environment safer.^{7,10,21,33-37} Fourteen programs implemented other universal fall precaution strategies.^{6,10,12,13,19,22,24,27,35,36,38-41}
3.3. What is a standardized assessment of risk factors for falls, and how should this assessment be conducted?	Based on the evidence review, the Morse Falls Scale and STRATIFY are the most thoroughly studied fall risk assessment tools. Both scales have established reliability and validity, but research has shown that the scores from these tools may not predict falls any better than a clinician's 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 be used for fall prevention care planning?	Thirty-five programs implemented structured care plans for fall prevention.^{1-3,5-15,20-22,25,27,30,32,33,35-42,46-50} 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 manage patients after a fall?	Thirteen programs conducted postfall reviews.^{2,9,11,18-22,24,27,32,33,52}
4.1. What roles and responsibilities will staff have in preventing falls?	Three programs implemented strategies to optimize roles and responsibilities to 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.^{10,18,3,2,35,48,54} Three additional programs implemented strategies to streamline documentation.^3,13,36
4.3. How do you put the new practices into operation?	Seven programs implemented strategies to promote unit-level buy-in.^{7,11,13,18,22,3,2,42} 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.^{6-8,12,15,17-19,22,24,3,2,35,45} 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 prevention practices?	Eighteen programs measured and monitored adherence to key processes of 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
6. How do you sustain an effective fall prevention program?	One program evaluated policy twice yearly to see if modifications were needed.⁴⁶ 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

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