Preventing Falls in Hospitals

Roadmap

Section Action Steps Tool That Supports Action Who Should Use The Tool
Overview Enlist support of senior leaders Word Version [ Microsoft Word file - 30.6 KB] ; Senior manager
Section 1 Are you ready for this change?
1.1 Assess the culture of safety in your hospital Tool 1A, Hospital Survey on Patient Safety Culture; Word Version [ Microsoft Word file - 49.85 KB] All interdisciplinary team members
1.2 Evaluate current organizational attention to falls Tool 1B, Stakeholder Analysis; Word Version [ Microsoft Word file - 30.26 KB] Implementation Team leader
1.3 Assess 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
1.5 Identify resources that are available and resources that are needed Tool 1E, Resource Needs Assessment; Word Version [ Microsoft Word file - 28.99 KB] Implementation Team leader
1.7 Assess your progress on completing readiness for change activities Tool 1F, Organizational Readiness Checklist; Word Version [ Microsoft Word file - 29.55 KB] Implementation Team leader
Section 2 How will you manage change?
2.1 Identify your Implementation Team Tool 2A, Interdisciplinary Team; Word Version [ Microsoft Word file - 40.94 KB] Implementation Team leader
2.2 Assess 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 prevention Tool 2E, Fall Knowledge Test; Word Version [ Microsoft Word file - 32.79 KB] Staff nurses and nursing assistants
2.3 Set goals for improvement based on outcomes and processes Tool 2F, Action Plan; Word Version [ Microsoft Word file - 34.66 KB] Implementation Team leader with quality improvement/safety/risk manager
2.4 Assess your progress on completing the managing change activities Tool 2G, Managing Change Checklist; Word Version [ Microsoft Word file - 29.25 KB] Implementation Team leader
Section 3 Which fall prevention practices do you want to use?
3.1 Identify how fall prevention care processes connect to one another Tool 3A, Master Clinical Pathway for Inpatient Falls; Word Version [ Microsoft Word file - 61.8 KB] Quality improvement/safety/risk manager, staff nurses, nursing assistants
3.2 Implement 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
3.3 Identify 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
3.4 Use identified fall risk factors to implement fall prevention care planning Tool 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
3.5 Assess 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
3.8 Assess your progress on completing the best practices activities Tool 3P, Best Practices Checklist; Word Version [ Microsoft Word file - 29.23 KB] Implementation Team Leader
Section 4 How do you implement the fall prevention program in your organization?
4.1 Assign 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
4.3 Assess current staff education practices and facilitate integration of new knowledge on fall prevention into existing or new practices Tool 4C, Assessing Staff Education and Training; Word Version [ Microsoft Word file - 30.88 KB] Implementation Team Leader
4.4 Assess your progress on implementing best practices activities Tool 4D, Implementing Best Practices Checklist; Word Version [ Microsoft Word file - 29.22 KB] Implementation Team Leader
Section 5 How do you measure fall rates and fall prevention practices?
5.1 Collect the right data to learn about falls, fall-related injuries, and their causes Tool 5A, Information To Include in Incident Reports; Word Version [ Microsoft Word file - 30.61 KB] Quality improvement/risk manager, information systems staff
5.2 Measure fall prevention practices Tool 5B, Assessing Fall Prevention Care Processes; Word Version [ Microsoft Word file - 41.74 KB] Unit manager and unit champions
5.3 Assess your progress on measuring progress activities Tool 5C, Measuring Progress Checklist; Word Version [ Microsoft Word file - 29 KB] Implementation Team Leader
Section 6 How do you sustain an effective fall prevention program?
6.3 Identify factors need to sustain your fall prevention efforts Tool 6A, Sustainability Tool; Word Version [ Microsoft Word file - 32.85 KB] Implementation Team Leader
Page last reviewed January 2013
Page originally created January 2013
Internet Citation: Roadmap. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtkmap.html
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