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

Roadmap


SectionAction StepsTool That Supports ActionWho Should Use The Tool
OverviewEnlist support of senior leadersTool ØA, Introduction and Overview for Stakeholders; Word® File (30 KB, Plugin Software Help)Senior manager
Section 1Are you ready for this change?
1.1Assess the culture of safety in your hospitalTool 1A, Hospital Survey on Patient Safety Culture; Word® File (50 KB, Plugin Software Help)All interdisciplinary team members
1.2Evaluate current organizational attention to fallsTool 1B, Stakeholder Analysis; Word® File (30 KB, Plugin Software Help)Implementation Team leader
1.3Assess and develop leadership support for the fall prevention programTool 1C, Leadership Support Assessment; Word® File (30 KB, Plugin Software Help)

Tool 1D, Business Case Form; Word® File (30 KB, Plugin Software Help)		Implementation Team leader
1.5Identify resources that are available and resources that are neededTool 1E, Resource Needs Assessment; Word® File (30 KB, Plugin Software Help)Implementation Team leader
1.7Assess your progress on completing readiness for change activitiesTool 1F, Organizational Readiness Checklist; Word® File (30 KB, Plugin Software Help)Implementation Team leader
Section 2How will you manage change?
2.1Identify your Implementation TeamTool 2A, Interdisciplinary Team; Word® File (40 KB, Plugin Software Help)Implementation Team leader
2.2Assess the current status of fall prevention activities in your hospitalTool 2B, Quality Improvement Process; Word® File (30 KB, Plugin Software Help)

Tool 2C, Current Process Analysis; Word® File (30 KB, Plugin Software Help)

Tool 2D, Assessing Current Fall Prevention Policies and Practices; Word® File (35 KB, Plugin Software Help)		Implementation Team leader, individuals designated by the Implementation Team leader
Determine staff knowledge about fall preventionTool 2E, Fall Knowledge Test; Word® File (33 KB, Plugin Software Help)Staff nurses and nursing assistants
2.3Set goals for improvement based on outcomes and processesTool 2F, Action Plan; Word® File (35 KB, Plugin Software Help)Implementation Team leader with quality improvement/safety/risk manager
2.4Assess your progress on completing the managing change activitiesTool 2G, Managing Change Checklist; Word® File (30 KB, Plugin Software Help)Implementation Team leader
Section 3Which fall prevention practices do you want to use?
3.1Identify how fall prevention care processes connect to one anotherTool 3A, Master Clinical Pathway for Inpatient Falls; Word® File (60 KB, Plugin Software Help)Quality improvement/safety/risk manager, staff nurses, nursing assistants
3.2Implement universal fall precautionsTool 3B, Scheduled Rounding Protocol; Word® File (30 KB, Plugin Software Help)

Tool 3C, Tool Covering Environmental Safety at the Bedside; Word® File (35 KB, Plugin Software Help)

Tool 3D, Hazard Report Form; Word® File (30 KB, Plugin Software Help)

Tool 3E, Clinical Pathway for Safe Patient Handling; Word® File (60 KB, Plugin Software Help)		Unit manager, staff nurses, nursing assistants, facility engineer, hospital employee who enters patient rooms
3.3Identify important risk factors for falls in your patientsTool 3F, Orthostatic Vital Sign Measurement; Word® File (33 KB, Plugin Software Help)

Tool 3G, STRATIFY Scale for Identifying Fall Risk Factors; Word® File (30 KB, Plugin Software Help)

Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors; Word® File (30 KB, Plugin Software Help)

Tool 3I, Medication Fall Risk Score and Evaluation Tools; Word® File (33 KB, Plugin Software Help)		Staff nurses, pharmacist, nursing assistants
3.4Use identified fall risk factors to implement fall prevention care planningTool 3J, Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method; Word® File (40 KB, Plugin Software Help)

Tool 3K, Algorithm for Mobilizing Patients; Word® File (100 KB, Plugin Software Help)

Tool 3L, Patient and Family Education; Word® File (30 KB, Plugin Software Help)

Tool 3M, Sample Care Plan; Word® File (33 KB, Plugin Software Help)		Educators, staff nurses, physicians, nurse practitioners, physician assistants, nursing assistants
3.5Assess and manage patients after a fallTool 3N, Postfall Assessment, Clinical Review; Word® File (35 KB, Plugin Software Help)

Tool 3O, Postfall Assessment for Root Cause Analysis; Word® File (45 KB, Plugin Software Help)		Staff nurses and physicians
3.8Assess your progress on completing the best practices activitiesTool 3P, Best Practices Checklist; Word® File (30 KB, Plugin Software Help)Implementation Team Leader
Section 4How do you implement the fall prevention program in your organization?
4.1Assign staff roles and responsibilities for tasks identified in set of best practicesTool 4A, Assigning Responsibilities for Using Best Practices; Word® File (30 KB, Plugin Software Help)

Tool 4B, Staff Roles; Word® File (30 KB, Plugin Software Help)		Implementation Team Leader, Unit manager
4.3Assess current staff education practices and facilitate integration of new knowledge on fall prevention into existing or new practicesTool 4C, Assessing Staff Education and Training; Word® File (30 KB, Plugin Software Help)Implementation Team Leader
4.4Assess your progress on implementing best practices activitiesTool 4D, Implementing Best Practices Checklist; Word® File (30 KB, Plugin Software Help)Implementation Team Leader
Section 5How do you measure fall rates and fall prevention practices?
5.1Collect the right data to learn about falls, fall-related injuries, and their causesTool 5A, Information To Include in Incident Reports; Word® File (30 KB, Plugin Software Help)Quality improvement/risk manager, information systems staff
5.2Measure fall prevention practicesTool 5B, Assessing Fall Prevention Care Processes; Word® File (40 KB, Plugin Software Help)Unit manager and unit champions
5.3Assess your progress on measuring progress activitiesTool 5C, Measuring Progress Checklist; Word® File (30 KB, Plugin Software Help)Implementation Team Leader
Section 6How do you sustain an effective fall prevention program?
6.3Identify factors need to sustain your fall prevention effortsTool 6A, Sustainability Tool; Word® File (33 KB, Plugin Software Help)Implementation Team Leader

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Current as of January 2013
Internet Citation: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care: Roadmap. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/fallpxtoolkit/fallpxtkmap.html