Falls and Fall Prevention in Adults

This guide outlines the steps that unit managers should follow to prevent falls:

Leadership Checklist

Use this checklist as a guide to determine whether current evidence-based guidelines are being followed in your organization.

1. Perform a baseline assessment of risk management data to understand the common causes of falls on inpatient units, applicable to all care areas (e.g., Pareto charts).
2. Expect that when the organization starts tracking safety events, there will be an initial increase in reported events before organizational improvement work begins to reduce error rates over time. Ensure that the frontline staff and leaders understand this so they don’t become demotivated to improve.
3. Ensure frontline involvement in falls improvement activities. Maintain their engagement and remove barriers to progress.
4. Ensure that falls protocols are embedded in clinical workflows, whether electronic or
5. Ensure there are enough clinically competent, trained staff to effectively manage necessary preventive See “Provide education and training” below for more information.
6. Ensure adequate training and documentation of falls screening and prevention competencies and skills.
7. Eliminate barriers to making rapid changes to documentation templates and order sets.
8. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
9. Hold staff accountable for providing the standard of care and reward success.
10. Reinforce just culture practices for staff members who report patient falls.
11. Ensure that leaders have a simple process to oversee falls improvement work while also considering how it aligns with other initiatives across the
12. Include patient and family voices in the fall prevention process.
13. Ensure fall prevention is organization-wide and that the responsibility does not fall on one discipline.
14. Adopt a standardized definition of falls with specific categorization criteria.
15. Standardize visual cues to indicate high-risk fall patients for staff members, in addition to ambulation equipment (e.g., color-coded gowns, wristbands, socks, etc.).
16. Review your falls data monthly at Quality and Patient Safety Committee meetings. Share tracked/trended falls data and lessons learned with frontline staff. Be transparent about causes of falls on unit and engage frontline staff in finding solutions to minimize those causes. It is not uncommon for frontline staff to not understand why falls data is being collected.
17. Create a tiered fall prevention program with involvement from those at the unit level, with outpatient providers, and at the leadership and systems levels to ensure when people move throughout the system, they are faced with the same protocols. Ensure comprehensive discipline representation.
18. Maintain inventory of appropriate tools for ambulation and injury prevention (e.g., hip pads, personal alarms, etc.).
19. Train non-clinical staff alongside clinical staff in identifying a patient at high risk, maintaining a safe environment, and calling for help.
20. Establish a standardized debrief process to examine all falls and near misses and analyze the system of safety practice for points of failure and opportunities for Standardize post-fall management protocol and include a post-fall huddle format.
21. Have a plan for sustainability.

Performance Improvement Plan

Follow this checklist if the leadership team has determined that a performance improvement project is necessary.

To grasp the current situation thoroughly, analyze objective data and trends, ensuring data sources are reliable. However, the key step is direct observation at the point of care. Even for those familiar with the area, examining processes from all angles is enlightening. Asking frontline staff questions during observation helps everyone understand each process step and identify necessary resources for enhancing patient outcomes.

Falls processes to consider assessing:

• Use of call light and response to call light
• Use of current assessment tools and how these assessments are performed and documented
• Assessment tools for specific populations (e.g., new mothers and newborns)
• Frequency of risk assessment
• Use of restraints
• How findings from root cause analyses are shared
• Staff knowledge of fall prevention for different populations and cultures

Evaluate outcomes, celebrate wins, and adjust the plan when necessary.

Measure both process and outcome metrics. Outcome metrics include the rates outlined below. Process metrics will depend upon the workflow you are trying to improve and are generally expressed in terms of compliance with workflow changes. Compare your outcomes against other related metrics your organization is tracking.

Routinely review all metrics and trends with both the advisory and project teams and discuss what is going well and what is not. Identify barriers to completion of action plans and adjust the plans if necessary. Once you have the desired outcomes in the trial area, consider expanding to other areas.

Typical gaps identified in falls improvement work:

1. Non-responsiveness to call lights
2. Equipment and environmental risks (e.g., beds that are too high)
3. Patients are not mobilized due to a fall risk
4. Bias in fall risk (e.g., ageism)
5. Gloss flooring (glare can reduce sight)
6. Lack of handrails in the room, walkways, and bathrooms
7. Windows with glare or without polarized coatings
8. Lack of clear definition of what constitutes a fall
9. Changes in patient’s medication/treatment without informing the patient about how it will impact their risk for falls
10. Lack of sensitivity to fall risk factors for those of different backgrounds (e.g., washing feet before prayer)

Fall metrics to consider assessing:

1. Fall rate
2. Falls with injury rate
3. Infant falls
4. Delirium assessments conducted
5. Restraint use
6. Use of visual cues for fall risk patients
7. Medications associated with falls

Factors that increase fall risk:

1. Prior history: History of a fall, history of bedrest, visual impairment
2. Cardiovascular: History of anemia or preeclampsia, orthostatic hypotension, dizziness
3. Hemorrhage: Postpartum hemorrhage (> 1,500 ml), placental abruption or previa
4. Neuro-function/anesthesia: Post-general, regional, or neuraxial anesthesia, paresthesia in the thigh, epidural infusion discontinued < 3 hours
5. Motor/activity: Able to straight leg raise but unable to bridge, unable to straight leg raise
6. Medications: IV/IM narcotics, anti-hypertensive, tocolytics, sleep aids

 Guiding principles related to fall prevention and protection from injury:

1. Many falls are predictable and preventable.
2. Fall prevention is a shared responsibility within healthcare and throughout the institution.
3. Person and family-centered care is foundational to the care of people at risk for a fall and fall injuries.
4. The risks and benefits for the person should be considered in partnership with patients and their advocates when implementing interventions for fall prevention and protection from injury.

 The performance gap in preventing falls

Many succeed temporarily due to a “placebo effect.” Simply raising staff awareness will only work to reduce falls for a short period of time.

 Environmental factors that may increase fall risk:

1. Furniture on wheels
2. Cluttered pathways
3. Poor lighting
4. Height of furniture
5. Slippery floors
6. Unit layout making it difficult to see patients from nurses’ station
7. Medical devices (IV poles, indwelling urinary catheters)
8. Glare from windows
9. High-gloss flooring

Situational factors that increase fall risk:

1. Leaning forward
2. Reaching up
3. Transferring on/off bed/chair

Use appropriate tools

Analysis of falls with injury in the Sentinel Event database of The Joint Commission revealed the most common contributing factors are:

1. Inadequate assessment
2. Communication failures
3. Lack of resources, including staffing
4. Lack of adherence to protocols and safety practices
5. Inadequate staff orientation, knowledge, supervision, or skill mix
6. Deficiencies in the physical environment
7. Lack of leadership 

Engage staff, patients, and families

1. Review interventions for fall prevention and protection from injury:
   1. Use visual cues to indicate high-risk fall patients for staff members, in addition to ambulation equipment:
2. Examples of visual cues: color-coded gowns, wristbands, socks, and external magnets
   1. Share this information with patients and families to raise their awareness of fall risks and your steps to prevent them.
   2. Solicit their agreement to help prevent falls as part of your care team.
3. Ensure those involved in medication regimes, including administration, understand their roles in fall prevention and protection from injury.

Define the types of falls:

Physiological (anticipated): Most in-hospital falls belong to this category. These are falls that occur in patients who have risk factors for falls that can be identified in advance, such as altered mental status, abnormal gait, frequent toileting needs, or high-risk medications.

Physiological (unanticipated): These are falls that often occur in a patient who is otherwise at low fall risk, because of an event whose timing could not be anticipated, such as a seizure, stroke, or syncopal episode.

Accidental: These falls occur in otherwise low-risk patients due to an environmental hazard. Improving environmental safety will help reduce fall risk in these patients but is helpful for all patients.

Categorize falls with injury:

1. No apparent injury
2. Minor injury: Bruises or abrasions as a result of the fall
3. Moderate injury: An injury that causes tube or line displacement, a fracture, or a laceration that requires repair, including application of steri-strips
4. Major injury: Injury that requires surgery or a move to the intensive care unit for monitoring a life-threatening injury
5. Death

Provide education and training

1. Ensure that rotations of students, volunteers, and new employees understand the importance of fall prevention and protection from injury actions.
2. Consistently educate newly admitted patients and their advocates on the importance of their partnership in reducing and avoiding falls. Clearly define their role and actions.
3. Get input from patients and families who themselves are managing conditions which put them or a loved one at risk for falls.
4. Create a post-fall huddle protocol.

Include guidelines on how to care for a patient that has fallen:

1. Once the immediate medical concerns of the fall have been addressed, perform a non-punitive root cause analysis, including the patient who fell and any family members who may have witnessed the fall.
2. There are two different types of root cause analyses: aggregate and individual.
3. Organizations should consider having both processes in place to assure maximum learning and improvement. Highly reliable institutions create a safe environment for staff members, patients, and their advocates to report any potential patient safety concerns.
   1. Without this safe reporter environment, true root causes will never be found, thus creating negative patient safety outcomes indefinitely.

Technology Plans

1. Data and data analytic systems capture and utilize patient information through wearables, such as sensors in garments and footwear.
2. Understanding the potential increased risk of newborn falls and drops is a challenge in today’s fast-paced healthcare environment. Utilizing principles of high reliability, including preoccupation with failure, a healthcare system should consider developing a process to help prevent newborn falls and drops for all infants under their care. This process should include:
   1. Developing an assessment tool to indicate those at increased risk for a newborn fall. This tool will promote common language and a shared mental model among the healthcare team and act as a cognitive aid to staff so all are performing assessment in a similar manner.
   2. Educating parents based on assessment. Those at highest risk should be counseled on the risks for newborn falls and drops and the need to call for help when feeling tired or sleepy.
   3. Cautioning parents against falling asleep with their newborn in the bed or co-sleeping with their newborn.
   4. Rounding hourly by staff so mothers or other caregivers noted to be drowsy can be assisted in placing their newborn in a bassinet.
   5. Promoting maternal rest.
   6. Developing signage for the patient room or a crib card to reinforce the increased risk of infant falls and the importance of placing the infant in a bassinet when the mother is sleepy or after the mother receives pain medications.
   7. Developing a standardized reporting and debriefing tool in the event of an infant fall. A standardized tool will help capture important data to better understand the risk and environment when the event occurred and result in consistent post-fall care for the newborn. In the event of a fall, provide emotional support to the family or caregiver who may suffer as a second victim in this event. Predictive modeling is being embedded into alert systems, such as communication and nurse call, and into electronic healthcare records.
3. Data analytics will drive advances in fall prevention and protection from injury. Technology is also advancing into the physical environment with systems designed to create safer environments. New advancements utilize high-performance monitoring systems to reduce physical sitters needed for individual observation.
4. Measure and report falls monthly (Falls/1,000 patient days). Note trends in areas with low screening and prevention compliance and high fall incidence. Routinely reassess outcomes.
5. Consider tracking and collecting inpatient falls data and outcomes post-discharge to monitor the frequency and cost of morbidity and mortality. Sustain focus on fall prevention with system-wide visibility on metrics at multiple touchpoints within the organization.

In the field of fall prevention and protection from injury, there is a focused approach to restore muscle strength and balance:

• In the inpatient arena, technology has influenced advancements in rehabilitation equipment that is supporting earlier mobilization.
• In the outpatient arena, exercising and classes such as tai chi have provided methods to help individuals at high risk for a fall with an overall approach to strengthening muscles.

While these classes are good, they are problematic for many patients. Emerging 3D technology and interactive games have the potential to be customizable to individual capabilities.

Approach technology use with the understanding that it is multifocal, evolutionary, and not static in both use and understanding. Investments of resources, both capital and human, are ongoing and need to be planned for as such.

Electronic Health Records can provide meaningful data that can inform predictive modeling, advances in patient safety, and further application of evidence into practice. It is only through interoperability of clinical systems that this can be achieved.