Patient Safety Topics

As healthcare facilities continually look to strengthen their falls prevention programs and respond to the high-risk problem of persistent patient falls, evaluation of falls events can provide additional opportunities to address this organization-wide challenge. The adoption of standardized strategies to reduce falls risk—including ongoing education about safe patient handling practices, handoff communications, and use of an assessment tool or checklist—helps to identify patient risk factors and could mitigate injurious patient falls.

Key Data and Statistics

​In 2012, the Pennsylvania Patient Safety Authority provided hospitals participating in the Pennsylvania Hospital Engagement Network Falls Reduction and Prevention Collaboration with two tools to evaluate their falls prevention programs: an annual self-assessment survey and a quarterly process measures audit. Hospitals that completed the survey in 2012 and 2013 reported an increase in full implementation for 16 of 17 categories of falls prevention best practices. Comparison of 2012 survey responses to audit results revealed a gap between levels of full implementation of best practices reported on the survey and compliance with falls prevention practices observed during the audit process. Analysis of 2013 data shows a decrease in this gap and improved compliance with falls prevention practices. Rates of falls with harm decreased for hospitals that completed the self-assessment survey in 2012 and 2013 in addition to all quarterly audits. Hospitals participating in the collaboration and utilizing these tools have been able to evaluate their current falls prevention programs, identify and implement evidence-based practices missing or in need of improvement, monitor staff compliance with falls prevention practices, and decrease rates of falls with harm.

Figure. Reported Percentage of Falls Prevention Best Practices with Full Implementation by Category for Hospital Engagement Network Facilities Completing the Falls Self-Assessment Survey Tool in 2012 and 2013 (N = 74)

Falls Prevention Best Practices with Full Implementation by Category for HEN Facilities Completing the Falls Self-Assessment 


Educational Tools

Ambulatory Surgical Facility Falls Risk Assessment Tool
Ambulatory surgical facilities can use this tool to screen patients for falls risk at three intervals: pre-admission, pre-operatively, and post-operatively.

The Chester County Hospital Patient Safety Assistant Orientation Manual
This sample orientation manual discusses expectations for patient safety assistants in one Pennsylvania healthcare system.

Falls Prevention Process Measures Audit Tool
This audit tool is intended to help assess compliance with falls prevention practices most commonly included as part of hospital falls prevention plans.

Falls Risk Checklist
This sample checklist can help determine whether the facility’s falls risk assessment tool screens for certain risk factors associated with greater risk of falls and  falls with injury.

Falls Self-Assessment Tool Action Plan
After completing a self-assessment tool (SAT), your falls prevention team is encouraged to create an action plan targeted to any best-practice elements that were identified on the SAT as missing or incompletely implemented in your facility’s current falls prevention program.

Falls with Harm Savings Calculator
This sample falls with harm savings calculator for hospitals can be used to calculate the average additional cost of falls with serious injury, additional days, and cost savings associated with reductions in falls with serious injury.

Hospital Engagement Network Falls Reduction and Prevention Collaboration Self-Assessment Tool
This self-assessment is intended to serve as a tool to evaluate the current structure and content of a hospital falls prevention program, compared with evidence-based best-practice guidelines, and to identify opportunities for improvement.

PA-PSRS Falls Event Type Decision Tree for Hospital Users
This decision tree is intended as a guide to help staff systematically evaluate the circumstances after a patient falls and assign an event type in the Pennsylvania Patient Safety Reporting System.

Pennsylvania Hospital Engagement Network: Falls Reduction and Prevention Collaboration Postfall Investigation Tool
The Postfall Investigation (PFI) Tool is designed to be used to collect information following a patient fall.

Hospital Improvement Innovation Network Injury from Falls and Immobility Postfall Investigation Data Collection Workbook
This data collection workbook is designed to be used for aggregating data about falls through use of the Pennsylvania Hospital Engagement Network Falls Reduction and Prevention Collaboration Postfall Investigation Tool.

Radiology Falls Risk Assessment Tool

This sample assessment tool may be used to alert radiologic technologists to a patient’s risks for falls.



Ensuring patients do not fall while in the hospital is critical to their safety and overall recovery. In this “I am Patient Safety” 2018 Best Video award winner, produced by UPMC Susquehanna - Williamsport Regional Medical Center, patients and caregivers are shown the keys they need to remember to prevent falls in a hospital setting.


Safety Tips for Patients