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Tool 0A: Introduction and Overview for Stakeholders

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

Word Version [ Microsoft Word file - 30.6 KB]

Background: This template can serve as a letter to key players in the hospital to introduce them to the goals and purpose of a fall prevention program.

Reference: Developed by Falls Toolkit Research Team.

How to use this tool: Adapt this letter as needed and present it to senior leaders to enlist their support before mounting your fall prevention program. You may want to use Tool 1B, "Stakeholder Analysis," to identify individuals and departments who may have an interest in the program.

Dear <Name>:

We would like to introduce you to our fall prevention program. We hope that you will support this exciting new endeavor.

What is this program? <Hospital name> is embarking on an important new initiative focused on the prevention of falls among our acute care patients.

Why is this program important? Falls with serious injury occurring during acute care stays represent a significant threat to patient safety, and increase the length of inpatient stays by 6.9 days and hospital charges by$13,806.xi In addition, falls with serious trauma have become a "never" event from the standpoint of Medicare reimbursement. Thus, falls represent both a patient safety priority and an economic priority for health care organizations. Fall rates are as high as <xxx falls per 1,000 bed days of care> on some of our units.

How might this program affect me/my area? In the past, fall prevention has sometimes been seen as solely a nursing unit responsibility. However, recent research makes it clear that successfully reducing fall incidence requires a coordinated interdisciplinary approach. Thus, the implementation of new prevention approaches may require, for example, the efforts of:

  • Materials management: Do we have the most evidence-based products and equipment needed to prevent falls? Are new products, such as hospital beds, evaluated with this outcome in mind?
  • Environmental services: Are environmental hazards in the hospital (e.g., spills, electrical cords) appropriately managed?
  • Information technology: Is information about fall prevention interventions effectively integrated into the electronic health record?
  • Pharmacy: Has the hospital formulary been reviewed to see if certain medicines (e.g., sleep aids) should be restricted in patients at risk for falls?
  • Physicians: Are patients' medications checked for their risk of causing falls? Is the patient's mental status formally tested where appropriate?
  • Rehabilitation services: Are protocols in place for ordering physical and occupational therapy? Are needed assistive devices (e.g., walkers, wheelchairs) available at the bedside? Are appropriate orders on file for patients' activity levels?
  • Quality improvement: Are quality improvement specialists available to assist the team working on this effort?
  • Transport: Are patients who are at high risk for falls supervised when taken off the unit for diagnostic or therapeutic activities?

What will happen? For this program, we will use the U.S. Agency for Healthcare Research and Quality's new toolkit. This comprehensive toolkit outlines steps in the improvement process and provides relevant tools. Using these tools, we will assess staff awareness and knowledge of fall prevention, analyze patient care processes to identify opportunities for improvement, and target interventions in those areas. Fall incidence while patients are under our care will be analyzed more closely so that progress can be assessed.

Everyone has a role: Most important in this effort is a shift of thinking and culture, from regarding falls as inevitable to seeing them as events that can be reduced through a comprehensive program. Your support in helping <hospital name> staff make this shift is essential to the success of this effort. Thank you.


xi Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf 2011;37(2):81-7. Available at http://www.ncbi.nlm.nih.gov/pubmed/21939135.


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Current as of January 2013
Internet Citation: Tool 0A: Introduction and Overview for Stakeholders: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool0a.html