Roadmap

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

SectionAction StepsTool That Supports ActionWho Should Use The Tool
OverviewEnlist support of senior leaders Word Version [ Microsoft Word file - 30.6 KB] ;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 Version [ Microsoft Word file - 49.85 KB] All interdisciplinary team members
1.2Evaluate current organizational attention to fallsTool 1B, Stakeholder Analysis; Word Version [ Microsoft Word file - 30.26 KB] Implementation Team leader
1.3Assess and develop leadership support for the fall prevention program

Tool 1C, Leadership Support Assessment; Word Version [ Microsoft Word file - 29.62 KB]

Tool 1D, Business Case Form; Word Version [ Microsoft Word file - 29.16 KB]

Implementation Team leader
1.5Identify resources that are available and resources that are neededTool 1E, Resource Needs Assessment; Word Version [ Microsoft Word file - 28.99 KB] Implementation Team leader
1.7Assess your progress on completing readiness for change activitiesTool 1F, Organizational Readiness Checklist; Word Version [ Microsoft Word file - 29.55 KB] Implementation Team leader
Section 2How will you manage change?
2.1Identify your Implementation TeamTool 2A, Interdisciplinary Team; Word Version [ Microsoft Word file - 40.94 KB] Implementation Team leader
2.2Assess the current status of fall prevention activities in your hospital

Tool 2B, Quality Improvement Process; Word Version [ Microsoft Word file - 30.48 KB]

Tool 2C, Current Process Analysis; Word Version [ Microsoft Word file - 30.33 KB]

Tool 2D, Assessing Current Fall Prevention Policies and Practices; Word Version [ Microsoft Word file - 33.9 KB]

Implementation Team leader, individuals designated by the Implementation Team leader
Determine staff knowledge about fall preventionTool 2E, Fall Knowledge Test; Word Version [ Microsoft Word file - 32.79 KB] Staff nurses and nursing assistants
2.3Set goals for improvement based on outcomes and processesTool 2F, Action Plan; Word Version [ Microsoft Word file - 34.66 KB] Implementation Team leader with quality improvement/safety/risk manager
2.4Assess your progress on completing the managing change activitiesTool 2G, Managing Change Checklist; Word Version [ Microsoft Word file - 29.25 KB] 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 Version [ Microsoft Word file - 61.8 KB] Quality improvement/safety/risk manager, staff nurses, nursing assistants
3.2Implement universal fall precautions

Tool 3B, Scheduled Rounding Protocol; Word Version [ Microsoft Word file - 29.92 KB]

Tool 3C, Tool Covering Environmental Safety at the Bedside; Word Version [ Microsoft Word file - 36.01 KB]

Tool 3D, Hazard Report Form; Word Version [ Microsoft Word file - 30.13 KB]

Tool 3E, Clinical Pathway for Safe Patient Handling; Word Version [ Microsoft Word file - 61.22 KB]

Unit manager, staff nurses, nursing assistants, facility engineer, hospital employee who enters patient rooms
3.3Identify important risk factors for falls in your patients

Tool 3F, Orthostatic Vital Sign Measurement; Word Version [ Microsoft Word file - 32.37 KB]

Tool 3G, STRATIFY Scale for Identifying Fall Risk Factors;

Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors

Tool 3I, Medication Fall Risk Score and Evaluation Tools

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;

Tool 3K, Algorithm for Mobilizing Patients; Word Version [ Microsoft Word file - 96.08 KB]

Tool 3L, Patient and Family Education; Word Version [ Microsoft Word file - 29.6 KB]

Tool 3M, Sample Care Plan; Word Version [ Microsoft Word file - 32.47 KB]
Educators, staff nurses, physicians, nurse practitioners, physician assistants, nursing assistants
3.5Assess and manage patients after a fall

Tool 3N, Postfall Assessment, Clinical Review; Word Version [ Microsoft Word file - 33.64 KB]

Tool 3O, Postfall Assessment for Root Cause Analysis; Word Version [ Microsoft Word file - 43.48 KB]

Staff nurses and physicians
3.8Assess your progress on completing the best practices activitiesTool 3P, Best Practices Checklist; Word Version [ Microsoft Word file - 29.23 KB] 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 practices

Tool 4A, Assigning Responsibilities for Using Best Practices; Word Version [ Microsoft Word file - 29.14 KB]

Tool 4B, Staff Roles; Word Version [ Microsoft Word file - 31 KB]

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 Version [ Microsoft Word file - 30.88 KB] Implementation Team Leader
4.4Assess your progress on implementing best practices activitiesTool 4D, Implementing Best Practices Checklist; Word Version [ Microsoft Word file - 29.22 KB] 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 Version [ Microsoft Word file - 30.61 KB] Quality improvement/risk manager, information systems staff
5.2Measure fall prevention practicesTool 5B, Assessing Fall Prevention Care Processes; Word Version [ Microsoft Word file - 41.74 KB] Unit manager and unit champions
5.3Assess your progress on measuring progress activitiesTool 5C, Measuring Progress Checklist; Word Version [ Microsoft Word file - 29 KB] 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 Version [ Microsoft Word file - 32.85 KB] Implementation Team Leader
Current as of January 2013
Internet Citation: Roadmap: 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/fallpxtkmap.html