Improve Your Falls Prevention Initiatives
Fall prevention and fall injury mitigation continues to be a priority for healthcare organizations across the continuum of care and for the patients that experience falls. Falls are a common event that can and do result in serious injury or death, especially in older patients. Research shows that approximately half of the 1.6 million people who live in a nursing facility in the US, and an estimated 700,000 to 1 million hospitalized patients, fall each year. In 2021, patient falls were the most frequently reported event type in Oregon’s Patient Safety Reporting Program (PSRP). As expected from the program’s emphasis on serious adverse events, the majority (66%) of those falls resulted in serious harm to the patient.
Top Contributing Factors Identified in PSRP Fall Reports
The most frequently selected categories of contributing factors associated with falls reported to PSRP in 2021 were Patient Factors (82% of reported falls) and Communication Factors (57% of reported falls). The top individual factors associated with reported falls were:
Patient physical limitations (20/44, 45%)
Patient sensory impairment (15/44, 34%)
Patient mental status (13/44, 30%)
Patient fragile health status (12/44, 24%)
Patient behavioral status (12/44, 24%)
Communication during handoffs (12/44, 24%)
What You Can Do
While falls can be difficult to prevent, we know the work to prevent falls, or mitigate injuries from falls, requires continuous diligence and should include:
Assessments of the physical environment to limit movements that lead to falls
Participation from both patients and providers
A multidisciplinary team approach that accounts for all perspectives of a fall event
Incorporation of patient demographics along with risk assessments
We’ve compiled some recent research on falls that your organization can use to enhance its falls prevention initiatives, as well as a selection of toolkits to guide your work. These resources align well with some of the falls prevention challenges identified in PSRP reports, and can be integrated into your organization’s ongoing quality and patient safety improvement work.
Enhance Your Falls Prevention Initiatives with the Latest Research
Physical Design Factors Contributing to Patient Falls
A 2021 study that identifies physical design elements that contribute to potential falls in patient rooms.
Key Takeaways
Physical designs should reduce turning and avoid motions that involve two or more postures, like turning and grabbing, during interactions with the physical environment, which constitute the source of most fall events.
Consider these questions: What are the characteristics of a bathroom that could reduce turning, grabbing, pushing, and pulling? What is the ideal toilet seat height and flush handle location? What are the ideal numbers, locations, and orientations of grab bars?
Patient Activation Related to Fall Prevention: A Multisite Study
A 2020 study that examines the impact of the Fall TIPS program on patient activation related to fall prevention.
Key Takeaways
Patients that have access to the Fall TIPS program had more knowledge about their fall prevention plan and had more confidence in their ability to prevent themselves from falling.
The Fall TIPS program addresses the digital divide by providing multiple modalities for all literacy levels.
Use of High-Fidelity Simulation to Enhance Interdisciplinary Collaboration and Reduce Patient Falls
A 2020 pilot study that shows the effect of nurse/physician interdisciplinary team training on patient falls to enhance collaboration between care disciplines.
Key Takeaways
Patient safety cannot succeed in preventative practices without opportunities for interdisciplinary teams to practice and apply critical-thinking skills in a realistic environment.
Interdisciplinary team training on patient falls targets and minimizes breakdowns in perceptions of respect, collaboration, communication, and role misunderstanding behaviors between care disciplines.
Using Electronic Health Records to Enhance Predictions of Fall Risk in Inpatient Settings
A 2020 study that shows how the enhanced fall algorithm (EFA) improves the accuracy of identification of patients at risk for falls compared with use of the Morse Fall Scale alone.
Key Takeaways
Adding patient demographics, chronic conditions, lab values, and medications, and controlling for clustering within unit, gathered by the electronic health record (EHR) improves the accuracy of risk detection.
Improving efficiency of staff resources with the enhanced fall algorithm (EFA) more accurately identifies patients at risk for falls, focusing risk reduction efforts on patients most likely to fall.
Use a Toolkit to Guide Your Work
A patient-centered falls prevention toolkit that provides a framework to help patients and family members work with nurses and other healthcare providers to reduce falls in hospitals.
Long-term Care Falls Investigation Toolkit: How-to Guide
This guide, which follows the root cause analysis (RCA) process, serves as a road map for the investigation indicating the sequence of events post-fall, through action plan development and monitoring for effectiveness.
AHA Team Training, includes TeamSTEPPS
Evidenced-based tools to improve team performance and increase staff and patient satisfaction are just a few of the benefits implementing AHA team training. The TeamSTEPPS Video Toolkit with multiple training modules will help foster the quality of teamwork.