Preventing Falls in Hospitals

Tool 2D: Assessing Current Fall Prevention Policies and Practices

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Background: The purpose of this self-assessment tool is to identify what processes of care your hospital has in place and what areas need improvement.

Reference: Adapted from AHRQ publication on the Falls Management Program for nursing homes.

How to use this tool: This tool should be filled out by the Implementation Team leader. Use your hospital's policies, procedures, and general practices to answer the questions.

The results from this self-assessment can help you identify which areas need improvement and develop a plan.

Current Fall Prevention Policies and Practices

A. Culture, Organizational Commitment, and Team Skills Yes No Comments
1. Updated policies and procedures for a comprehensive fall prevention program?      
2. Appointed falls team leader and resource person for staff?      
3. Selection of staff members for interdisciplinary falls team?      
4. Monthly falls team meeting using ground rules, leader, timekeeper, and recorder?      
5. High-level managers attend team meetings periodically and monitor falls data at least quarterly?      
6. No blame/no shame environment with honest investigation and reporting by staff?      
7. Celebration of success stories and rewards for caregivers who reduce falls?      
8. Adequate staffing for team leader to spend 8 hours/week and team to meet for 60 minutes/month?      
9. Funds for adaptive equipment and environmental modifications?      
10. Employee orientation materials emphasize importance of and hospital commitment to patient safety?      
B. Data Collection and Analysis Yes No Comments
1. Accurate completion of fall incident report form by all staff?      
2. Monthly falls analysis by: Location and time of fall      
Shift and day of week      
Type of injury      
3. Monthly falls analysis computed as falls/1,000 patient-days?      
4. Falls data reported to hospital management every quarter?      
5. Feedback about falls data given to direct care staff each month?      
6. Falls data trended over 6 months or more?      
C. Staff Training and Information for Patients and Families Yes No Comments
1. Education on fall prevention during new employee orientation and training?      
2. Annual inservice training on fall prevention for all staff?      
3. Staff education materials, including:
  • Hospital policies and procedures.
  • Fall risk factors and consequences of falls.
  • High-risk medications, sleep hygiene measures for management of anxiety.
  • Low blood pressure precautions.
  • Low vision precautions.
  • Safety during transfer, ambulation, and wheelchair use.
  • Unsafe behaviors, monitoring devices, and management strategies.
  • Environment and equipment safety hazards and methods for improvement.
  • Foot care and footwear.
4. All nurses trained in a fall response system that includes:
  • Immediate evaluation and increased monitoring of patient.
  • Investigation of fall circumstances.
  • Documentation of fall.
  • Immediate intervention within first 8 hours.
5. Information for families and patients on fall risk reduction?      
6. Medical staff given information about the program and their role?      
D. Environment and Equipment Safety Yes No Comments
1. Regular inspection of all resident rooms and bathrooms for safety problems, including:
  • Clutter.
  • Poor or insufficient lighting.
  • Unstable furniture.
  • Hard-to-reach personal items.
  • Unsafe flooring.
  • Foot care and footwear.
2. All staff trained to inspect and report environmental and equipment safety problems?      
3. Repair of reported safety problems in a timely manner by maintenance staff?      
4. Inspection and repair of all wheelchairs, canes, and walkers every 6 months?      
5. Communications and inspections documented for ongoing monitoring and accountability?      

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Page last reviewed January 2013
Page originally created January 2013
Internet Citation: Tool 2D: Assessing Current Fall Prevention Policies and Practices. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD.