A Quality Improvement Initiative for Nursing Facilities
The Falls Management Program presented in this manual is an interdisciplinary quality improvement initiative. It is designed to assist nursing facilities in providing individualized, person-centered care, and improving their fall care processes and outcomes through educational and quality improvement tools.
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By Jo A. Taylor, R.N., M.P.H.
Patricia Parmelee, Ph.D.
Holly Brown, M.S.N., A.P.R.N.-B.C.
Joseph Ouslander, M.D.
Developed and supported by the
Agency for Healthcare Research and Quality (AHRQ)
#290-00-0011, Task Order No. 3.
A program of
Center for Health in Aging and the
Emory University Division of Geriatric Medicine
and Gerontology, Department of Medicine
1841 Clifton Road, Atlanta, Georgia, 30329;
Chapter 1. Introduction and Program Overview
Chapter 2. Fall Response
Chapter 3. Data Collection and Analysis Using TRIPS
Chapter 4. Long-Term Management
Chapter 5. Information and Training for Staff, Primary Care Providers,
and Residents and their Families
Chapter 6. Environment and Equipment Safety
Appendix A. References and Equipment Sources
Appendix B. Forms and Training Materials
Appendix C. Case Study and Program Examples
Appendix D. Falls Engineer Instructions
We gratefully acknowledge the expert advice of Elizabeth Capezuti, R.N., Ph.D. and
Harry Strothers, M.D. and the invaluable work of Walton Harris in preparing the
The Falls Management Program builds upon the previous work of Dr. Wayne Ray
and colleagues at the Vanderbilt University School of Medicine. Several components
of the program and illustrations in this publication are used courtesy of the Department
of Preventive Medicine in the Vanderbilt University School of Medicine.
Lucy Rogers, Pam O'Rourke, Ken Brouse and others at Ethica Healthcare Retirement
Communities were instrumental in the development of the Tracking Record for
Improving Patient Safety and have provided insightful feedback and assistance for
The information in this manual and the other program materials are intended to supplement
the knowledge of nursing and medical staff. The instructions for altering the environment or
adapting equipment as well as other care processes may not be applicable in your setting. Before
using any of the adaptations or items, all available information concerning the resident
as well as particular circumstances of the environment and equipment must be carefully evaluated
by staff. The information provided in this manual is advisory only and is not intended
to replace sound clinical judgment or individualized resident care. Contents of this manual
do not necessarily reflect Centers for Medicare & Medicaid Services (CMS) policy or endorsement.
Current as of February 2010
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities. February 2010. Rockville, MD, Agency for Healthcare Research and Quality. http://www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm