Pa Patient Saf Advis 2013 Dec;10(4):117-24.
Falls Prevention: Pennsylvania Hospitals Implementing Best Practices
Author

Michelle Feil, MSN, RN
Senior Patient Safety Analyst
Pennsylvania Patient Safety Authority

Abstract

The Pennsylvania Patient Safety Authority provided 83 hospitals participating in the Pennsylvania Hospital Engagement Network (HEN) Falls Reduction and Prevention Collaboration with two tools to evaluate their falls prevention programs: a self-assessment survey and a process measures audit. The survey results revealed two categories of best practices with high levels of full implementation: event reporting and postfall assessment. The three categories of best practices with the lowest levels of full implementation were medication review, communication, and use of sitters. Comparing survey responses with the audit results revealed a noticeable gap between levels of full implementation of best practices reported on the survey and compliance with falls prevention practices observed during the audit. Analyses of survey results and hospital rates of falls with injury identified 35 individual falls prevention practices and/or specific program elements that were associated with lower rates of falls with injury. Assessing level of implementation of best practices in falls prevention, auditing for compliance, and analyzing results in relation to rates of falls with injury can identify significant strengths and weaknesses in current hospital falls prevention programs.

Introduction*

In December 2011, the Pennsylvania Patient Safety Authority partnered with the Hospital and Healthsystem Association of Pennsylvania to lead the Pennsylvania Hospital Engagement Network (HEN) Falls Reduction and Prevention Collaboration. This collaboration is funded by the Partnership for Patients initiative established by the Center for Medicare and Medicaid Innovation (also known as the Innovation Center). Between January and May 2012, 83 hospitals from across the commonwealth joined the collaboration and enrolled in the Pennsylvania Patient Safety Reporting System (PA-PSRS) Falls Reporting Program.

A major focus of the collaboration continues to be to ensure that hospitals are implementing evidence-based practices in falls prevention. Education provided to hospitals in the collaboration has included a review of what is currently established as best practice based on individual, high-quality research studies and systematic reviews, as well as evidence-based falls prevention guidelines.1-9

The Authority developed two tools for hospitals in the collaboration to use in evaluating their falls prevention programs: the Hospital Engagement Network Falls Reduction and Prevention Collaboration Self-Assessment Tool (SAT) survey and the Falls Prevention Process Measures Audit Tool. As a result of facilities using these tools and sharing their findings, the Authority has been able to (1) identify which best practices in falls prevention are being included in participating hospital falls prevention programs, (2) measure compliance with implementation of best practices, and (3) identify specific falls prevention best practices associated with higher or lower rates of falls with injury. The falls SAT survey and the Falls Prevention Process Measures Audit Tool can be accessed at http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Pages/home.aspx.

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* The analyses upon which this publication is based were in part funded and performed under contract number HHSM-500-2012-00022C, entitled “Hospital Engagement Contractor for Partnership for Patients Initiative.”

Methods

Falls SAT Survey

The falls SAT survey was adapted from an existing questionnaire10 and was designed to evaluate the current structure and content of hospital falls prevention programs compared with evidence-based best-practice guidelines. The intent of the SAT survey was to assist hospitals in creating action plans targeted to the best-practice elements that were identified as missing or in need of improvement in their current falls prevention programs.

Falls Prevention Process Measures Audit Tool

The Falls Prevention Process Measures Audit Tool is a point prevalence data collection tool used to assess compliance with falls prevention practices most commonly included as part of hospital falls prevention programs. Hospitals were asked to complete quarterly audits on the unit or units where they were piloting small tests of change as part of the HEN collaboration. The audit consisted of documentation review (e.g., “Was  falls prevention plan documented?”) and observation of patients and the environment (e.g., “Does patient have risk identifiers?”).

Falls-with-Injury Rates and Falls SAT Survey Responses

Rates of falls with injury per 1,000 patient-days were calculated for January through June 2012 using falls with harm as reported through PA-PSRS (i.e., any fall requiring more than first-aid care11) and total facility patient-days as reported to the Pennsylvania Health Care Cost Containment Council (PHC4).12 Complete data was available for 75 of the 80 hospitals that responded to the falls SAT survey. For 18 hospitals reporting zero falls with injury during this period, an event count of 0.01 falls was used in order to permit inclusion in the meta-analysis. Rates of falls with injury in these 75 hospitals were analyzed alongside falls SAT survey responses to assess any association between specific falls prevention best practices and falls-with-injury rates.

First, a DerSimonian and Laird random-effects meta-analysis of the logit-transformed rates per patient-day at each facility was performed. Hospitals with more patient-days were weighted more heavily in this analysis than hospitals with fewer patient-days because they provide more statistically reliable information about the rates of falls with injury. Subsequently, random-effects meta-regressions were performed to measure the associations between rates of falls with injury and both categories of prevention practices, as well as between rates of falls with injury and individual falls prevention program elements.

Results

Falls SAT Survey

Eighty hospitals completed the falls SAT survey between July 5 and August 31, 2012.The majority of hospitals reported full implementation for the majority of best practices in falls prevention. Hospitals reported full implementation of an average of 71% of best practices (range of 22% to 93%). Figure 1 displays the average percentage of full implementation of best practices reported by hospitals, organized by category. The range of responses in all these categories reveals the variation present across all 80 HEN hospitals that completed the falls SAT survey.

Figure 1. Percentage of Falls Prevention Best Practices with Full Implementation, by Category

Figure 1. Percentage of Falls Prevention Best Practices with Full Implementation, by Category
Falls prevention practices with high levels of full implementation. Two categories of falls prevention best practices within the falls SAT survey scored highest in terms of full implementation: event reporting and postfall assessment. Fifteen hospitals reported all best practices in the event reporting category as fully implemented. The only two questions that all 80 hospitals scored as “Yes” were also in this category: “Does your facility use a standardized patient safety event report for internal purposes to document and report fall hazards, falls, and falls with harm?” and “Does it [the report] require staff to include the date and time of the fall?”

Falls prevention practices with low levels of full implementation. Medication review was the lowest-scoring category of the falls SAT survey in terms of level of full implementation of best practices. This category included six best practices, four of which the majority of hospitals reported as not having implemented (see Table 1).

Table 1. Levels of Full Implementation of Falls Prevention Best Practices in the Category of Medication Review ​ ​ ​ ​

Falls Self-Assessment Tool Survey Question

Yes* (%)

P/I (%)

No (%)
No Response (%)
Do pharmacists review patient medication regimens for potential falls risks when filling medication orders? 26.2515.0056.252.50
Is there a requirement that the pharmacist inform the prescriber and the nursing staff if prescribed medications increase the risk of falling? 10.006.2581.252.50
Does the pharmacist recommend alternative medications to reduce the patient's risk of falling if the prescribed medications increase the risk of falling?12.5012.5072.502.50
Does the facility's pharmacy and therapeutics committee periodically review formulary medications to identify those that increase falls risk and make recommendations about those medications?13.7512.5071.252.50
Are physicians encouraged to modify or eliminate prescribed medications that increase the risk of falling?36.2516.2546.251.25
Do nurses have access to a list of medications that increase an individual's risk of falling that is used when assessing patients for falls risks?40.0015.0042.502.50

Note: As reported by 80 facilities in the Hospital Engagement Network. Shaded areas indicate the percentage of hospitals with no response or reporting no implementation for each best-practice question.

* YES = full implementation
P/I = partial implementation/needs improvement
NO = no implementation

 

The second lowest scoring category was communication. This category consisted of six best practices, three of which were reported to have an average full implementation of 75% or less: (1) “When the patient is transferred for testing, therapy, or to another unit, is there a process in place for communicating the individual’s risk of falling directly to the transporter and to the receiving party?”; (2) “Are indicators promptly removed once a patient is transferred or discharged?”; and (3) “Do visible indicators of a patient’s risk for falling display on the nurse call system workstation?” The last question was one of the lowest-scoring questions of the survey, with only four hospitals responding “Yes.” As shown in Figure 1, this is also the only category of falls prevention practices for which no hospitals reported more than 50% of best practices to be fully implemented.

The third lowest scoring category was sitters, or one-to-one observation. Of the 48 hospitals that reported having sitter programs, only 21 reported full implementation of all six best practices (i.e., the sitter program includes patient eligibility criteria, a process for requesting and discontinuing sitters, criteria for sitter qualifications, a sitter job description with expectations for sitter behavior and responsibilities, a training program for sitters, and a pool of sitters).

Also of note is that only 47 hospitals (59%) reported full implementation of a multidisciplinary falls team with participants from all sectors of the facility (e.g., clinical personnel, nonclinical personnel, senior managers). The majority of hospital teams included nurses, but many were lacking pharmacists and physical therapists, and even more did not include physicians or nonclinical personnel.

Falls Prevention Process Measures Audit Tool

Sixty-three hospitals submitted baseline point prevalence audits between July 1 and September 30, 2012. A total of 1,894 patients were audited, of which 1,847 (98%) had completed falls risk assessments and 1,292 (68%) were identified as being at risk to fall. Of the patients identified as being at risk to fall, most had a call bell within reach (91%), documentation of a falls prevention plan (88%), two siderails in the up position (81%), and nonskid socks or slippers (76%). Falls risk identifiers, specialty equipment, and alarms were found to have lower levels of implementation. Table 2 details the percentage of patients at risk to fall that were found to have each falls prevention practice in place.

Table 2. Hospital Engagement Network Facilities' Compliance with Falls Prevention Practices in Patients Identified as Being at Risk to Fall (N = 1,292) ​
falls prevention practice falls-risk patients (%)
Call bell within reach91
Falls prevention plan documented88
Special equipment is in use: two siderails up81
Patients have appropriate footwear: nonskid socks or slippers76
Patient and family education documented66
Hourly rounds documented66
Patients have risk identifiers: wrist band54
Special equipment is in use: low bed36
Patients have risk identifiers: sign outside room34
Alarms are in use: bed alarm28
Patients have risk identifiers: colored socks20
Patient have risk identifiers: sign inside room17
Alarms are in use: chair alarm9
Patients have risk identifiers: other8
Patients have appropriate footwear: rubber-soled shoes6
Special equipment is in use: other4
Special equipment is in use: floor mat3
Patients have risk identifiers: colored blanket2
Alarms are in use: other2
Sitter is in place2
Patients have appropriate footwear: other1
Special equipment is in use: hip protectors0
Note: As assessed through use of the Falls Prevention Process Measures Audit Tool, July through September 2012.

     

These audits were considered a baseline assessment of compliance with falls prevention practices for the hospitals participating in the collaboration.

Comparison of falls SAT survey responses to audit results revealed a noticeable gap between levels of full implementation of best practices reported on the falls SAT survey and compliance with falls prevention practices observed during the audit process (see Figure 2). For instance, in facilities reporting full implementation of wristbands used to communicate falls risk, only 61% of patients at risk to fall were found to have falls risk wristbands in place.

Figure 2. Compliance with Use of Falls Risk Indicators in Hospitals Reporting Full Implementation on the Falls Self-Assessment Tool Survey, July through September 2012Figure 2. Compliance with Use of Falls Risk Indicators in Hospitals Reporting Full Implementation on the Falls Self-Assessment

Seventy-five hospitals that had completed the falls SAT survey had complete data available to calculate rates of falls with injury for the period of January through June 2012. The overall estimated rate of falls with injury per 1,000 patient-days for this group was 0.21 (95% CI: 0.17 to 0.26), with large variability among hospitals. The top quartile of hospitals had rates ranging from 0.26 to 2.50 falls with injury per 1,000 patient-days.

Falls-with-Injury Rates and Falls SAT Survey Responses

Of 139 individual falls prevention best practices included in the falls SAT survey, meta-regression analyses were completed for 136 practices. The other three were excluded because they were reported as fully implemented at all 75 hospitals. These three were assessment and documentation of a patient’s risk for falling in the patient’s medical record on admission; use of a standardized patient safety event report for internal purposes to document and report fall hazards, falls, and falls with harm; and requiring staff to include the date and time of the fall in the event report.

Falls prevention practices associated with lower rates of falls with injury. Meta-regression analyses revealed 5 of 17 categories of falls prevention practices with statistically reliable associations (p < 0.05) with lower rates of falls with injury: (1) falls prevention program design, (2) benchmarking, (3) policies and protocols, (4) assessing risk, and (5) postfall assessment.

Further analyses identified 35 individual falls prevention practices and/or specific program elements that were also associated with lower rates of falls with injury (p < 0.05). See “Falls Prevention Practices and Program Elements Associated with Lower Rates of Falls with Injury.” Also of note is that while use of a specific color to communicate falls risk was found to be associated with lower rates of falls with injury, no one color was found to be associated with reductions or increases in rates of falls with harm.

Falls prevention practices associated with higher rates of falls with injury. No category of falls prevention practices was found to have a statistically reliable association with higher rates of falls with injury. However, hospitals reporting higher levels of full implementation of practices in the falls alarms category tended to have higher rates of falls with injury, with a nearly statistically reliable association (p = 0.056).

In analyzing individual falls prevention practices, three practices in the categories of patient monitoring, patient and family education, and postfall assessment, respectively, demonstrated a statistically reliable association (p < 0.05) with higher rates of falls with injury: (1) “When possible, are high-risk patients located in rooms closest to nursing stations?”; (2) “Are patients who are at risk of falling instructed to avoid ambulating or getting out of bed without assistance?”; and (3) “Under this policy, are staff required to (and educated on how to) complete a patient safety event report?”

Lastly, in analyzing specific falls prevention program elements, it was shown that hospitals that reported designing custom risk assessment tools had reliably higher rates of falls causing harm (p < 0.05).

Discussion

In the Pennsylvania HEN Falls Reduction and Prevention Collaboration to date, the Authority has been able to do the following: (1) identify which best practices in falls prevention are being included in participating hospital falls prevention programs, (2) measure compliance with implementation of best practices, and (3) identify specific falls prevention best practices associated with higher or lower rates of falls with injury.

The three categories of falls prevention best practices with the lowest levels of full implementation (medication review, communication, and sitters) deserve attention. Hospitals reported an average of 50% of best practices in these categories as fully implemented. Of particular concern are the two categories found to be significantly associated with lower rates of falls with injury but reported to have low levels of full implementation: medication review and sitters. Also worthy of discussion are falls prevention practices associated with higher rates of falls with injury, as well as the apparent “policy-practice gap” (i.e., interventions prescribed by policy are not implemented in practice) that was identified when comparing best practices reported as having full implementation on the falls SAT survey with falls prevention practices observed during the audit process.

Medication Review

The link between medications and falls risk has been well established, both in terms of specific drug classes and polypharmacy.13-17 The impact of medication on falls risk may be more pronounced in older adults but affects younger adults as well.18

Best practices in medication review related to falls risk have been put forth as part of several evidence-based falls prevention guidelines; however, the potential additional cost associated with implementing these practices may be one reason why they continue to have low levels of implementation. Further research into both the clinical effectiveness and cost effectiveness of these practices is warranted.17 Because this category of falls prevention practices scored lowest in terms of full implementation, hospitals participating in the collaboration have been encouraged to devote attention to this area, beginning with inclusion of pharmacists on falls prevention teams.

Communication

In the category of communication, the best practices in falls prevention that were lacking full implementation involved communication of falls risk beyond the patient and the nurse caring for the patient (e.g., falls risk is communicated in the medical record, falls risk is communicated to other departments, falls risk indicators display on the nurse call system workstation). Even in hospitals reporting full implementation of falls risk indicators, audits revealed low compliance with their use in patients at risk to fall.

If risk is not communicated to others (e.g., during patient handoff), then the responsibility for falls prevention cannot be shared. Research suggests that falls prevention is only effective when it is multifactorial and provided by a multidisciplinary team.19 Reinforcing this research is the finding in the current analysis of an association between falls prevention teams that include physicians and transportation managers or representatives and lower rates of falls with injury (see “Falls Prevention Practices and Program Elements Associated with Lower Rates of Falls with Injury”). It was reported that less than a third of falls prevention teams included these roles. By failing to communicate falls risk beyond the patient and the nursing staff, the multidisciplinary team cannot be engaged and the effectiveness of any prevention efforts may be lost.

Figure 3 displays the primary roles of falls team members as reported by HEN facilities.

 Figure 3. Inclusion in Falls Prevention Team, by Role, as Reported by 80 Hospital Engagement Network Facilities

Sitter Programs

The current analysis revealed an unexpected significant association between use of sitter programs and lower rates of falls with injury among hospitals in the collaboration. While the use of sitters, or one-to-one observation, has been suggested in several evidence-based falls prevention guidelines,1,5,7,9 research into the clinical effectiveness of sitter programs has produced inconsistent results.20 In addition, the use of these programs has been questioned, especially in the current economic environment, due to the high costs associated with their maintenance. This may explain the low utilization of sitter programs reported by hospitals participating in the collaboration.

The significant association found between low rates of falls with injury and the use of sitter programs, along with specific sitter program elements, suggests that hospitals currently using or considering establishment of sitter programs may benefit from ensuring adherence to best practices in administering and implementing the program.

Falls Prevention Practices Associated with Higher Rates of Falls with Injury

The practices of placing high-risk patients in rooms closest to nursing stations and instructing patients to avoid ambulating or getting out of bed without assistance were two individual falls prevention practices found to have statistically significant associations with higher rates of falls with injury in the current analyses. Likewise, the category of falls alarms showed an association with higher rates of falls with injuries.

One possible explanation for this association may be that these practices may be used more frequently in hospitals that provide care to a larger number of older adults, who have a higher risk of falls and injury (e.g., fracture risk secondary to osteoporosis, bleeding risk due to anticoagulant use in patients with atrial fibrillation). Because these interventions may be necessary in high-falls-risk populations, evaluation of their effectiveness may be better achieved through tracking falls and falls-with-injury rates as they relate to changes in implementation of these practices over time.

Educating and requiring staff to complete patient safety event reports for falls was another practice found to be associated with higher rates of falls with injury. This may be explained by improved recognition and adherence to standard definitions for reportable falls events. In a culture working to improve patient safety and transparency, falls rates may appear to increase in concert with increased reporting for all adverse events.21

The association found between high rates of falls with injury and use of facility-designed falls risk assessment tools requires further evaluation by hospitals. The Authority has published previously about the importance of falls risk assessment and evaluation by the hospital falls prevention team of the validity of facility-designed risk assessment tools. If validity cannot be confirmed, the Authority suggests using an evidence-based falls risk assessment tool with established validity.22

Falls Prevention Practices Not Shown to Be Associated with Rates of Falls with Injury

In the current analyses, many falls prevention practices were found to have no association with rates of falls with injury. The data only provides associations, not inferences about cause and effect. The sample size and methodology may be insufficient to detect differences documented by other studies.

Policy-Practice Gap

Hospital falls prevention team members completing the falls SAT survey reported full implementation of the majority of best practices in falls prevention. The results of the audits completed at 63 hospitals participating in the HEN collaboration suggest otherwise. While it is important to include best practices in hospital policies and falls prevention program guidelines, assessment of the degree to which staff implement these practices with consistency and reliability, especially in patients identified as being at risk to fall, is vital.

Design of an audit process and customization of an audit tool specific to the falls prevention practices of interest in individual hospitals is suggested as part of falls prevention performance improvement efforts. Continual reassessment and improvement of hospital falls prevention programs is dependent on information gained from audits and information from postfall investigations. When compliance with falls prevention practices is low, it is the work of the multidisciplinary falls prevention team to use this information to identify barriers and design solutions.

Limitations

The falls SAT survey was administered at hospitals in July and August 2012, whereas the data used to calculate falls-with-injury rates was collected for the period of January through June 2012. It is therefore possible that hospitals implemented falls prevention measures in July and August and indicated full implementation on the falls SAT survey even though the practices were not in place when the falls with injury were occurring.

Compliance with implementation of best practices in falls prevention practices was not able to be calculated for all hospitals participating in the HEN falls collaboration. Only 63 hospitals submitted audit data. It is possible that compliance with falls prevention practices may have been higher or lower across the 83 participating hospitals. In addition, while meta-regression analyses have yielded a list of falls prevention practices that are associated with higher or lower rates of falls with injury, cause and effect cannot be inferred.

Data used in calculating falls-with-injury rates is dependent on accuracy and consistency in reporting falls and identifying injury level through PA-PSRS. Hospitals included in this analysis have agreed to a consensus definition for falls and falls with injury as a condition for participation in the HEN falls collaboration; therefore, this limitation should have been minimized. The consensus definition was introduced in March 2012, which may have affected reporting in the baseline period. This data is also dependent on accurate and complete reporting of total facility patient-days to PHC4.

Conclusion

Multiple guidelines and toolkits exist to guide and support hospitals in implementing evidence-based best practices in falls prevention. Use of a self-assessment tool, such as the falls SAT survey, can be instrumental in identifying gaps between current hospital programs and evidence-based guidelines. Establishing a hospital falls prevention team and developing falls prevention policies alone is not sufficient. Use of a tool, such as the Falls Prevention Process Measures Audit Tool, is essential for monitoring compliance with falls prevention practices.

Hospitals may consider focusing attention on falls prevention best practices that the Authority has found to be associated with higher or lower rates of falls with injury. The effectiveness of falls prevention process improvement efforts may be assessed through monitoring for changes in falls and falls-with-injury rates over time as adjustments are made to falls prevention practices. Careful analysis of the associations between falls prevention practices and falls rates is warranted.

Acknowledgments

Jonathan R. Treadwell, PhD, associate director, Evidence-Based Practice Center, ECRI Institute, consulted on and contributed to statistical testing for this article. Christina Hunt, RN, MSN, MBA, HCM, senior patient safety liaison, Pennsylvania Patient Safety Authority, HEN Falls Reduction and Prevention Collaboration project team leader, consulted on and contributed to the review of this article. Denise M. Barger, BA, CPHRM, CPHQ, CPPS, HEM, patient safety liaison, Delaware Valley-South, and Richard M. Kundravi, BS, patient safety liaison, Northwest Region, contributed to the design and administration of the falls SAT survey and the Falls Prevention Process Measures Audit Tool as members of the HEN Falls Reduction and Prevention Collaboration project leadership team.

Notes

  1. Institute for Clinical Systems Improvement. Health care protocol: prevention of falls (acute care) [online]. 2012 Apr [cited 2012 May 15]. https://www.icsi.org/_asset/dcn15z/Falls.pdf
  2. Registered Nurses’ Association of Ontario. Prevention of falls and fall injuries in the older adult [online]. 2011 [cited 2012 May 15]. http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf 
  3. Patient Safety First. The ‘how-to guide’ for reducing harm from falls [online]. 2009 Sep [cited 2012 May 15]. http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-support/FALLSHow-to%20Guide%20v4.pdf
  4. Gray-Micelli D, Quigley PA. Fall prevention: assessment, diagnoses, and intervention strategies. In: Boltz M, Capezuti E, Fulmer T, eds. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York: Springer Publishing Company; 2012:268-97. Also available at http://www.guideline.gov/content.aspx?id=43933
  5. Boushon B, Nielsen G, Quigley P, et al. Transforming care at the bedside how-to guide: reducing patient injuries from falls [online]. 2008 [cited 2013 May 8]. http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx
  6. Health Care Association of New Jersey. Fall management guidelines [online]. 2007 Mar [cited 2013 May 8]. http://www.hcanj.org/docs/hcanjbp_fallmgmt6.pdf
  7. National Center for Patient Safety. National Center for Patient Safety 2004 falls toolkit [online]. 2004 Jul [cited 2013 May 8]. http://www.patientsafety.va.gov/SafetyTopics/fallstoolkit
  8. National Institute for Clinical Excellence. Clinical practice guideline for the assessment and prevention of falls in older people [online]. 2004 Nov [cited 2013 May 8]. http://www.nice.org.uk/nicemedia/pdf/CG021fullguideline.pdf
  9. Agency for Healthcare Research and Quality. Preventing falls in hospitals: a toolkit for improving quality of care [online]. 2013 Jan [cited 2013 May 8]. http://www.ahrq.gov/research/ltc/fallpxtoolkit/index.html
  10. ECRI Institute. Falls [self-assessment questionnaire]. Healthc Risk Control 2012 May;1:Self-assessment questionnaires 1.
  11. Arnold TV, Barger DM. Falls rates improved in southeastern Pennsylvania: the impact of a regional initiative to standardize falls reporting. Pa Patient Saf Advis [online] 2012 Jun [cited 2013 Sep 30]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Jun;9(2)/Pages/37.aspx
  12. Pennsylvania Health Care Cost Containment Council (PHC4) [website]. [cited 2013 Aug 5]. Harrisburg (PA): PHC4. http://www.phc4.org
  13. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009 Nov 23;169(21):1952-60.
  14. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 1999 Jan;47(1):30-9.
  15. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc 1999 Jan;47(1):40-50.
  16. Medication assessment: one determinant of falls risk. Pa Patient Saf Advis [online] 2008 Mar [cited 2012 Jun 14]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Mar5(1)/Pages/16.aspx
  17. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003 Dec 8-22;163(22):2716-24.
  18. Kool B, Ameratunga S, Robinson E. Association between prescription medications and falls at home among young and middle-aged adults. Inj Prev 2012 Jun;18(3):200-3.
  19. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older adults in nursing care facilities and hospitals. Cochrane Database Syst Rev 2010 Jan 20;(1):CD005465.
  20. Harding AD. Observation assistants: sitter effectiveness and industry measures. Nurs Econ 2010 Sep-Oct;28(5):330-6.
  21. Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Qual Saf Health Care 2009 Feb;18(1):5-10.
  22. Feil M, Gardner LA. Falls risk assessment: a foundational element of falls prevention programs. Pa Patient Saf Advis [online] 2012 Sep [cited 2013 May 13].
    http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Sep;9(3)/Pages/73.aspx

Supplemental Material

Falls Prevention Practices and Program Elements Associated with Lower Rates of Falls with Injury

Falls-with-injury rates were calculated for the time period of January through June 2012 for 75 facilities that completed the falls self-assessment tool survey in July and August 2012. The following individual falls prevention practices and specific falls prevention program elements were found to have statistically significant associations with lower rates of falls with injury in these 75 facilities (p < 0.05).

Falls Prevention Program Design
  • Formation of a falls prevention team that includes the following roles:
    • Physicians
    • Transportation managers or representatives
  • Design and implementation of a falls prevention program that does the following:
    • Defines the goals of the falls team and responsibilities of each member
    • Performs ongoing assessment of the program’s effectiveness (at least annually)
    • Develops and revises protocols and policies when necessary to support the goal of preventing falls
Benchmarking
  • Use of an external benchmark to compare facility falls rates
Policies and Protocols
  • Development of a facility falls prevention policy that includes the following:
    • A requirement for when an individual should be reassessed for risk
    • A description of appropriate responses to falls, including protocols for postfall investigation
    • A process for revising assessment and intervention strategies based on data
    • A plan to promote awareness of falls risks and prevention
Assessing Risk
  • Assessment of falls risks for both inpatients and outpatients
  • Requirement of routine reassessment of patients for their falls risks
  • Periodic facility review of the effectiveness of falls risk assessment tools
  • Use of the Hendrich II Fall Risk Model
  • Use of the General Risk Assessment for Pediatric Inpatient Falls tools
Evaluating the Environment
  • Requirement for patients to wear slip-proof socks or shoes
Medication Review
  • Periodic review by the facility’s pharmacy and therapeutics committee to identify formulary medications that increase falls risk and to make recommendations about those medications
  • Encouragement of physicians to modify or eliminate prescribed medications that increase the risk of falling
Patient Monitoring and Sitters (One-to-One Observation)
  • Performance of hourly rounds
  • Requirement for staff to stay with patients who are identified as being at risk to fall while in the bathroom
  • Use of sitter programs
  • Design of sitter programs to include the following:
    • Criteria for sitter qualifications
    • A training program for sitters
    • A pool of sitters
Staff Education
  • Provision of falls prevention education to staff that
    • occurs at orientation and periodically thereafter or as needed,
    • addresses the roles and responsibilities of staff as part of the falls prevention education program, and
    • includes education for intrinsic (clinical) and extrinsic (environmental) causes of falls for staff members involved in direct patient care, as appropriate for the staff members’ roles and responsibilities
Patient and Family Education
  • Provision of direct education to patients and their family members regarding the causes of falls and the interventions used to prevent falls
Communicating Patient Risk
  • Use of a specific color to identify patients as being at risk to fall
  • Use of falls risk wristbands
Postfall Assessment and Event Reporting
  • Implementation of a policy on how to respond to patient falls
  • Educating and requiring staff to do the following:
    • Document the fall in the patient’s medical record
    • Request a postevent systems analysis or postfall investigation
  • Reassessment of patients following a fall for falls risk and communication of findings to staff who interact with the patient
  • Use of a standardized patient safety event report for internal purposes, requiring staff to include extrinsic (environmental) factors
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