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FALLS Prevention

This supplement was funded by anunrestricted educational grant from Posey.Content of this supplement was developedindependently of the sponsor and all articleshave undergone peer review according toAmerican Nurse Today standards.

28 American Nurse Today Volume 10, Number 7 www.AmericanNurseToday.com

his year marks the 20-yearmilestone of the AmericanNurses Association’s

(ANA) leadership in making patientfalls a nurse-sensitive indicator. In1995, ANA’s work on nurse-sensi-tive indicator development resultedin the Nursing Care Report Card forAcute Care. This report includedfalls as a nurse indicator, demon-strating that nurses play an impor-tant role in outcomes in this area.

Fast-forwarding 20 years, nursesshould ask themselves, “How hasour practice changed? What moreneeds to be done to prevent falls?”Here are a few answers to thesequestions.

First, the rigor of science andgraded evidence-based practicesthat address reduction of fall riskfactors (not level of risk) or injuryrisk has gained momentum withinand across health care. However,more needs to be done to addressvariability, duration, and power ofthe research so conclusions aremore generalizable.

Second, in some healthcare or-ganizations, such as the Departmentof Veterans Affairs (VA), registerednurses are assessing both fall- andfall-injury risk and history as part ofthe admission process. This practiceneeds to widen to other hospitalsand healthcare settings. Toolkits help with this process (see the VA

toolkit at www.patientsafety.va.gov/professionals/onthejob/falls.asp). Es-tablishing effective strategies for im-plementation that will help ensurea culture change is a study arearich with opportunity.

Third, we now understand thatall patients in acute-care, long-termcare, and long-term acute-care hospi-tals as well as in home care are atrisk for falls. However, at-risk popu-lations must be emphasized to everynurse, no matter what role or setting.

Finally, as nurses, we must relyon our clinical expertise and judg-ment to engage in population-specific fall- and injury-preventionprograms as part of an interdiscipli-nary team. An interdisciplinary ap-proach is key because the evidenceis clear: Fall-prevention programsthat include only nurses aren’t ef-fective. It takes a team to make adifference.

The team needs to considersobering statistics, such as thesefrom the Centers for Disease Con-trol and Prevention:• In the next 13 seconds, an older

adult will be treated in a hospitalemergency department (ED) forinjuries related to a fall.

• In the next 20 minutes, an olderadult will die from injuriescaused by a fall.

• Falls cause more than half (55%)of traumatic brain injuries among

children ages 0 to 14 years.• People ages 85 and older are 10

to 15 times more likely to sustainhip fractures from falls than peo-ple ages 60 to 65.These statistics reflect the vulner-

ability of those we care for andmust drive changes in practice.They should support changes toyour organization’s fall and fall-in-jury programs that are population-specific based on age group, injuryrisk, and gender. As a start, everyorganization should answer the fol-lowing questions: 1. Does your organization manage

falls prevention for the veryyoung and the very old different-ly than for someone who’s iden-tified at risk for a fall?

2. Does your organization protectpatients who are admitted be-cause of a fall or fall while inyour care (“known fallers”) dif-ferently than those who are atrisk of falling?

3. Does your organization imple-ment a fall-injury risk and injury-protection program for patientswho are admitted with a fall-related injury or have a historyof a fall-related injury?

4. If a patient comes to your ED af-ter a fall and is discharged (notadmitted to the hospital), doesyour organization make a follow-up call to the patient to ask if heor she has fallen since returninghome? Your answers to these four ques-

tions will help identify areas ofneeded change. Read the articles inthis Focus on…Falls Prevention sec-tion to find ideas and strategies forkeeping patients safe from falls andto reduce injuries resulting fromfalls.

Let’s hope it doesn’t take 20more years to make even greaterinroads in improving patient out-comes related to falls prevention. •

Patricia Quigley is associate director for the VISN 8Patient Safety Center of Inquiry at the James A.Haley Veterans’ Hospital in Tampa, Florida.

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We’ve made gains inpreventing falls, butmore work remains

It takes a team to make adifference in falls prevention.

By Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP

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www.AmericanNurseToday.com July 2015 American Nurse Today 29

n estimated 25,500Americans died fromfalls in healthcare and

community settings in 2013.Countless more suffered life-changing injuries, such as frac-tures, internal injuries, and trau-matic brain injury. Expertsestimate that more than 84% ofadverse events in hospital patientsare related to falls, which can pro-long or complicate recovery. Thisarticle identifies risk factors forfalls, explains how falls are classi-fied, and describes how to per-form a fall-risk assessment.

To monitor falls incidence in aconsistent manner, healthcare pro-fessionals need to agree on thedefinition of a fall. A widely ac-cepted definition is “an unplanneddescent to the floor with or with-out injury to the patient.” Thenursing diagnosis for risk of falls is“increased susceptibility to fallingthat may cause physical harm.”

To help identify patients’ riskfactors for falls and guide inter-ventions to prevent falls in acute-care settings, falls commonly areclassified as anticipated physiolog-ic falls, unanticipated physiologicfalls, or accidental falls.

In addition, some cliniciansclassify risk factors as intrinsic orextrinsic. Intrinsic risk factors forfalls—those originating within theindividual—include:• low blood pressure or orthosta-

tic hypotension caused bystanding, dehydration, or mus-cle weakness (most notable inthe lower extremities)

• impaired mobility, unstablegait, and poor balance due topain, musculoskeletal deformi-ties, or neurologic disorders

• limited physical-activity en-durance

• foot problems that cause painor paresthesias (such as periph-eral neuropathy)

• impaired vision due to poordepth perception, glaucoma, orcataracts.

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Assessing yourpatients’ risk for fallingA systematic process toaddress patients’ fall risk can decrease or nearlyeliminate falls.By Beverly Lunsford, PhD, RN, CNS-BC and Laurie Dodge Wilson, MSN, APRN,AGPCNP-BC

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Extrinsic risk factors originateoutside the individual. They in-clude conditions in the physicalenvironment, such as poor light-ing, clutter, a slippery floor due toa spill, and an uneven threshold.

Risk factors for anticipatedphysiologic fallsRisk factors for anticipated physio-logic falls include an unstable orabnormal gait, a history of falling,frequent toileting needs,altered mental status,and certain medica-tions. Among hos-pitalized olderadults, about 38%to 78% of falls canbe anticipated. Evi-dence shows thatone-third of re-portable falls withinjuries in hospital-ized older adultsare linked to bath-room use; more than halfare associated with med-ications known to con-tribute to falls, such as an-tianxiety and antipsychotic drugs.Also, about 40% of falls occurwithin 30 minutes of an hourlyrounding visit by healthcareproviders.

Assess the patient for diseasesand disorders that affect the car-diovascular, respiratory, neurolog-ic, or musculoskeletal system. Al-so consider possible effects oftreatment for these diseases; manymedications increase the fall riskby causing dizziness, drowsiness,or confusion. Perform a thoroughmedication reconciliation to iden-tify potential high-risk drugs, in-cluding over-the-counter products(such as diphenhydramine, com-monly used for allergic rhinitis oras a sleep aid). As a rule ofthumb, the more medications apatient uses, the higher the fallrisk due to adverse drug effectsand drug-drug or drug-disease in-teractions. Also, make sure you’re

familiar withthe American Geriatric

Society Beers Criteria for po-tentially inappropriate medicationuse in older adults.

Risk factors for unanticipatedphysiologic fallsRisk factors for unanticipatedphysiologic falls include condi-tions such as seizures, syncopalepisodes, and delirium. These fallsmay occur with a temporarychange in physical or cognitivefunction and unfamiliar surround-ings. Such falls may be unantici-pated if the patient is otherwise atlow risk for falls.

Direct nursing interventions to-ward post-fall care and preventinginjury in case of another fall. Cur-rently, no tool exists to guidenurses and other healthcare teammembers in assessing risk for in-jury from unanticipated falls. Per-sons ages 85 or older, those withosteoporosis, and those taking anticoagulants are at greatest riskof injury from these falls.

Riskfactors for accidentalfallsAccidental falls can stem from slip-ping, tripping, or other accidents.They’re frequently linked to extrin-sic factors. To help reduce risk,evaluate the physical environmentcontinually for safety hazards. Beaware that falls in hospitals andother acute-care settings most of-ten occur in patient rooms, whenpatients are alone, or when theyattempt to go to the bathroom.Many hospitals are reevaluating thedesign of patient rooms and bath-rooms to decrease environment-re-lated falls. A redesign that enablesnurses to document at the bedsiderather than at a remote station pro-vides increased patient-safety sur-veillance and decreases the poten-tial for falls.

Be sure to consider assistive de-vices when evaluating extrinsicrisk factors that can cause acciden-tal falls. Canes, walkers, and

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Fall-risk assessment instruments

A systematic review of valid and reliable risk-assessment tools for acute, long-term, community, and home-support care settings found that no single tool is rec-ommended for implementation in all settings or for all subpopulations. However,the Morse Fall Scale (MFS) and St. Thomas Risk Assessment Tool in Falling ElderlyInpatients (STRATIFY) are well validated for assessing fall risk in adults. Healthcare providers can use the MFS to assess fall risk through multiple safety

indicators, including a history of falling, secondary diagnoses, ambulatory aid,gait, and mental status. The STRATIFY Tool has five items that address risk factorsfor falling, including past history of falling, agitation, visual impairment affectingeveryday function, need for frequent toileting, transfer ability, and mobility.STRATIFY should be used in conjunction with a clinical assessment and medica-tion review. Preferably, the review should be done by anurse or pharmacist using a standard list of medications, such as the Beers Criteria.


wheelchairs are meant to increasethe patient’s support and improvebalance and mobility. But manypatients aren’t properly taught howto use them; in some cases, thedevice is damaged or the wrongsize for the patient. In long-termcare facilities, the highest inci-dence of falls occurs during trans-fers—when the patient moves fromwheelchair to bed or gets up froman unbraked wheelchair. Physicaltherapists can help evaluate assis-tive devices and determine if theyare the right size and are beingused properly; they also can pro-vide education on their use.

Also consider other extrinsicrisk factors for accidental falls. Forinstance, check the patient’sfootwear and clothing, which canaffect mobility. Are the patient’s

pants too long?

Fall-riskscreening andassessment Screening and as-sessment can helpnurses and otherhealthcare profes-sionals identify pa-tients at risk for

falls. Fall-risk screening determinesif the patient is at risk for falls andindicates whether a more in-depthmultifactorial assessment should bedone. Fall-risk assessment providesa systematic way to check for validand reliable causes of falls in aparticular patient and identify fac-tors for which interventions areknown to reduce the fall risk.

ScreeningWhen screening patients for fallrisk, check for: • history of falling within the

past year• orthostatic hypotension• impaired mobility or gait• altered mental status• incontinence• medications associated with

falls, such as sedative-hypnotics

and blood pressure drugs• use of assistive devices.

Also, be aware that patients teth-ered to I.V. lines or other equip-ment are at increased risk for falls.

AssessmentIn long-term and acute-care set-tings, fall-risk assessment is re-quired for all patients on admission,transfer to a new unit, after achange in the level of care or thepatient’s condition, and after a fall.Because falls have multifactorialcauses, an interprofessional teamshould collaborate in the compre-hensive assessment. A standard as-sessment combines a systematic as-sessment with clinical decisionmaking, targeted interventions, careplanning, and communication withother healthcare professionals.

Nearly 50 fall-risk assessment in-struments exist. Typically, thesetools use a scoring system thatmeasures the cumulative effect ofknown risk factors. (See Fall-riskassessment instruments.) When se-lecting an assessment tool, focuson identifying key risk factors thatcan guide interventions to reduceor mitigate fall risk.

Some tools use a scoring systemwith cut-off values for patients athigh risk. But even if the patienthas a low score, don’t let this dis-tract you from implementing inter-ventions to reduce the risk offalling if the patient has identifi-able and preventable risks. Also,be aware that if all or many pa-tients are placed in a high-risk cat-egory, staff may be less likely toindividualize care plans when par-ticular risks are identified for aparticular patient.

Information from the assessment

guides diagnosis and implementa-tion of a consistent plan of care. Acritical step in this multifacetedprocess is communicating the pa-tient’s fall risk and required inter-ventions to colleagues, the patientand family, and significant otherswho need to support the interven-tions. Using a systematic processto identify and address the fall riskcan nearly eliminate anticipatedfalls, prevent unanticipated fallsfrom recurring, and significantlydecrease accidental falls. •

Beverly Lunsford is an assistant professor in theSchool of Nursing at George Washington University(GW) in Washington, DC; director of GW’s Center forAging, Health and Humanities; and director of theWashington D.C. Area Geriatric Education Center Con-sortium. Laurie Dodge Wilson is an assistant clinicalprofessor at GW School of Nursing.

Selected referencesAgency for Healthcare Research and Quality.Preventing falls in hospitals: a toolkit for im-proving quality of care. January 2013.www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html

American Geriatrics Society, British GeriatricsSociety. AGS/BGS clinical practice guideline:prevention of falls in older persons. NewYork, NY: American Geriatrics Society; 2010.

American Geriatric Society. 2012 AGS Beerscriteria for potentially inappropriate medica-tion use in older adults. www.americangeriatrics.org/files/documents/beers/2012AGSBeersCriteriaCitations.pdf

Boushon B, Nielsen G, Quigley P, et al.How-to guide: reducing patient injuries fromfalls. Cambridge, MA: Institute for HealthcareImprovement; 2012. www.ihi.org/resources/Pages/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.aspx

Centers for Disease Control and Prevention.STEADI (Stopping Elderly Accidents, Deathsand Injuries). Make STEADI part of yourmedical practice. Last updated May 12, 2015.www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html

Stevens JA, Phelan EA. Development ofSTEADI: a fall prevention resource for healthcare providers. Health Promot Pract. 2013;14(5):706-14.

Willy B, Osterberg CM. Strategies for reduc-ing falls in long-term care. Ann LongtermCare. 2014; 2(1). www.annalsoflongterm-care.com/article/strategies-for-reducing-falls-long-term-care

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To help reduce risk,evaluate the physical

environmentcontinually for safety

hazards.


alls pose a major publichealth problem aroundthe world. In the United

States, unintentional falls occur inall age groups. Such falls are theleading cause of nonfatal injuriestreated in emergency departments(EDs) among all age groups exceptages 10-14 and 15-24, for whomthese falls are the second leadingcause.

Commonly called “never events,”injurious falls can cause significantmorbidity and mortality. Some 3%to 20% of inpatients fall at leastonce during their hospital stay. Al-so, adults ages 65 and older ac-count for 70% of inpatient bed daysin hospitals; advanced age is an in-dependent risk factor for falls.

We need to accept that all pa-tients in our care are at risk forfalling. For this reason, nurses whopractice in any setting and care forpatients of any age should be ac-tively involved in patient safety andfall-prevention awareness and inter-ventions. This article summarizesrecommendations regarding keyfall precautions for patients underthe direct care of registered nurses(RNs) in acute or long-term set-tings. Key precautions fall intothese categories:

• Follow the nursing process.• Reduce the risk of falls.• Protect patients from injury if a

fall occurs.

Follow the nursing processEvery RN learns about the nursingprocess—assessment, diagnosis,outcome identification, planning,implementation, and evaluation.You must carry out all steps of thisprocess for each patient to ensurethat you’ve assessed fall risk factorsand that the assessment leads to adiagnosis. Communication and col-laboration among interdisciplinaryteam members are crucial.

The nursing process and nursingjudgment—not electronic recordswith templated checkbox notes—should drive patient care. A pri-mary characteristic of nursing prac-tice is that it’s individualized foreach patient. Unless you completeall the nursing process steps, indi-vidualized fall-prevention plans ofcare aren’t established with the pa-tient, caregivers, and interdiscipli-nary team.

Reduce the risk of fallsThe three main types of falls areaccidental falls, anticipated physio-logic falls, and unanticipated physi-

ologic falls. This article focuses onthe first two. (For more informationon preventing falls, including unan-ticipated physiologic falls, see “As-sessing your patients’ risk forfalling” in this special section.)

Reducing fall risk also includessurveillance. (See Surveillance op-tions.)

Reducing accidental fall riskAccidental falls can result from anunsafe environment or environmen-tal risk factors. To reduce the riskof these falls, maintain a constantawareness of environmental safetyand take the following actions:• Eliminate slipping and tripping

hazards.• Keep the bed at the proper

height duringtransferand

whenthe patientrises to a standingposition.

• Don’t keep the bed in a low po-sition at all times.

• Check chairs, toilets, and safetygrab bars for potential safetyproblems.

• Use proper room lighting.• Make sure the patient wears

proper footwear (not just non-skid socks). Also, conducting environmental

rounds helps nurses identify andmodify environmental fall and in-jury risks. Such rounding provides

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Taking appropriateprecautions against falls Learn about key fall

precautions for patients inacute or long-term settings.

By Patricia Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP

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a structured method for recordingwhen and where risks exist, as-signing responsibility to correctthem, establishing resolution dates,and setting a follow-up date forresolution.

Reducing anticipated physiologic fall riskAnticipated physiologic falls canstem from known intrinsic or ex-trinsic risk factors. • Intrinsic risk factors include im-

paired vision, gait, or balance;lower-extremity sensory neu-ropathy; orthostatic hypotension;and confusion.

• Extrinsic risk factors include cer-tain medications and mobilityaids, such as canes and walkers.To identify extrinsic risk factors,perform a comprehensive multi-factorial assessment. Evidencesupports the use of multifactorialfall-prevention programs for re-ducing falls and injuries in acute-care settings. To reduce the risk of anticipated

physiologic falls, use interventionstailored to the patient’s identifiedrisk factors. For example, if the pa-tient has elimination problems, im-plement anticipated toileting; for apatient with sleep deficits, suggestalternative sleep hygiene methods(listening to talking books or softmusic or getting a backrub) ratherthan sleep medications. If the pa-tient has impaired gait or balance,keep mobility aids within reach andprovide a referral to rehabilitationservices.

Protect patients from injury if a fall occursRecent fall-prevention toolkits have

focused on assessment and treat-ment of modifiable fall and injuryrisks, along with population-specificapproaches. In other words, youshould assess all patients (especiallythose older than age 65) for fall in-jury risk and history.

Be aware that interventions meantto protect patients from injury areseparate and distinct from those usedto prevent falls. For instance, if thepatient has a history of a hip fracture,surveillance practices (for example,rounding), protective equipment(such as floor mats and hip protec-tors), and possibly technology (forexample, video surveillance and chairalarms) should be used, regardlessof the patient’s score on a fall-riskscreening tool. Strategies to reducetrauma and injury, such as usingfloor mats and hip protectors andeliminating sharp edges, have beenintegrated into toolkits and practicefor older adults for more than 10years. Helpful toolkits are availablefrom multiple agencies, such as theDepartment of Veterans Affairs, Insti-tute for Healthcare Improvement, In-stitute for Clinical Systems Improve-ment, Agency for HealthcareResearch and Quality, and the Min-nesota Hospital Association.

As nurses, we can significantlyreduce the risk of falls and de-crease the rates of patient falls andinjuries caused by falls by using ourclinical judgment and expertise, in-dividualizing each patient’s care,and broadening fall prevention toinclude injury risk and protectionfrom injury. •

Patricia Quigley is associate director for the VISN 8Patient Safety Center of Inquiry at the James A.Haley Veterans’ Hospital in Tampa, Florida.

Selected referencesAgency for Healthcare Research and Quality.Preventing falls in hospitals: a toolkit for im-proving quality of care. 2013. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

American Nurses Association. Nursing: Scopeand Standards of Practice. 2nd ed. SilverSpring, MD: Author; 2010.

Boushon B, Nielsen G, Quigley P, et al.Transforming Care at the Bedside How-toGuide: Reducing Patient Injuries from Falls.Cambridge, MA: Institute for Healthcare Im-provement; 2012. www.safetyandquality.health.wa.gov.au/docs/squire/IHI%20Guide_Reducing_Patient_Injuries_from_Falls.pdf

Degelau J, Belz M, Bungum L, et al.; Insti-tute for Clinical Systems Improvement (ICSI).Health Care Protocol. Prevention of Falls(Acute Care). Bloomington, MN: ISCI; 2012.

Dykes PC, Carroll DL, Hurley A, et al. Fallprevention in acute care hospitals: a ran-domized trial. JAMA. 2001;304(17):1912-8.

Morse JM. Preventing Patient Falls: Establish-ing A Fall Intervention Program. 2nd ed.Thousand Oaks, CA; Springer PublishingCo.; 2008.

National Center for Health Statistics. 10 lead-ing causes of injury deaths by age grouphighlighting unintentional injury deaths,United States—2013. 2013. www.cdc.gov/injury/images/lc-charts/leading_causes_of_injury_deaths_highlighting_unintentional_injury_2013-a.gif

National Institute for Health and Care Excel-lence. Falls: Assessment and prevention offalls in older people. Guideline 161. 2013.www.nice.org.uk/guidance/cg161/chapter/1-recommendations.

Oliver D, Healey F, Haines TP. Falls and fall-related injuries in hospitals. Clin GeriatrMed. 2010;26(4):645-92.

Shekelle PG, Wachter RM, Pronovost PJ, etal. Making health care safer II: an updatedcritical analysis of the evidence for patientsafety practices. Evid Rep Technol Assess(Full Rep). 2013;(211):1-945. www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html

Spoelstra SL, Given BA, Given CW. Fall pre-vention in hospitals: an integrative review.Clin Nurs Res. 2012;21(1):92-112.

U.S. Department of Veterans Affairs. VA Na-tional Center for Patient Safety. Falls Toolkit.2014. www.patientsafety.va.gov/professionals/onthejob/falls.asp

Williams T, Szekendi M, Thomas S. Ananalysis of patient falls and fall preventionprograms across academic medical centers. JNurs Care Qual. 2014;29(1):19-29.

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Surveillance options

Monitoring patients is an essential part of preventing falls and injury caused by afall. Technology options for surveillance, such as bed and chair alarms and cameratechnology, continue to evolve. As with other interventions, use of technology should be individualized to the

patient; not all types of technology work for all patients. Also, plans must be putin place to evaluate the effectiveness of technology and other prevention tools.

alls are a major concernfor older adults in all set-tings, causing significant

morbidity and mortality and affect-ing quality of life. In the hospital,falls occur at an estimated rate of8.9 per 1,000 patient days. About30% to 50% of these falls cause injury. Falls increase hospital staysand may necessitate a long-termstay.

According to the Centersfor Disease Control andPrevention (CDC), 22,900older people died fromfall-related injuries in 2011.Falls also are linked to de-pression, anxiety, and fearof falling. In personswho’ve fallen, the risk offalling again rises signifi-cantly. Obviously, we mustput effective measures intoplace to prevent falls.

The literature on fallsprevention is abundant,and many fall-risk assess-ment instruments exit.Clinical practice guidelineson reducing falls recom-mend a multicomponentstrategy that addressesfunctional, physical, psy-

chological, and educational aspectsof falling, individualized to each pa-tient. Locating and reviewing theseguidelines is easy, but integratingthem into practice and individualiz-ing them for each patient can provechallenging.

Efforts to improve falls preven-tion require a systemic approachthat involves organizational change.Falls prevention should be part of

an organizational culture of evi-dence-based practice (EBP). EBPentails integration of clinical expert-ise, patient values, and the best re-search evidence into the decision-making process for patient care. Anessential component of professionalnursing practice, EPB is also a criti-cal component of the MagnetRecognition® and Pathway to Excel-lence® programs of the AmericanNurses Credentialing Center.

Using an appropriate EBP model Multiple models or frameworks canbe used to implement EBP. TheIowa Model of Evidence-BasedPractice is a trusted model that’seasy to understand and use. It takesa systematic approach to analyzinga problem and gathering researchto identify reasonable actions to ad-dress it, followed by practicechanges to reduce recurrence of theproblem, with subsequent critiqueand continued monitoring to sus-tain desired outcomes. This modelcan be used to develop an interdis-ciplinary plan to reduce falls inclinical settings.

After identifying the problem(such as a high number of falls,falls with injuries, or failure to re-

Creating anenvironment of falls prevention

Evidence-based practice canreduce falls and fall-related

injuries.By Sharon Stahl Wexler, PhD, RN-BC, FNGNA, and Catherine O’Neill D’Amico,

PhD, RN, NEA-BC

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duce falls using current interven-tions), interdisciplinary staff fromone or more units can gather themost recent falls-related literature inall fields and evaluate its suggesteduse in the practice setting. After thisliterature review and critique, theteam develops a set of actions andpilots a project using fall-risk as-sessment and prevention actionsidentified in the literature thatmatch the units’ populations andsettings. After a suitable interval,the interdisciplinary team evaluatesdesired outcomes of the EBP proj-ect. Based on results, changes topractice are introduced throughoutthe organization.

Two EBP falls-preventionprojectsThe EBP projects discussed belowillustrate how organizations can in-tegrate falls prevention into a cul-ture of EBP.

Community hospital’s med-surg unit A med-surg unit of a suburbancommunity hospital already hadan active and effective falls-pre-vention program in place, withfall rates below national bench-marks. But hospital leaderswanted to reduce rates even fur-ther. The EBP project used clini-cal practice guidelines from theAmerican Geriatrics Society andBritish Geriatrics Society, whichrecommend a multicomponentstrategy addressing functional,physical, and psychological as-pects of falling, tailored to pa-tients’ individual needs.

Clinicians partnered with thepatient and engaged the pa-tient’s active participation in thefalls prevention program. Thismulticomponent patient-engage-ment strategy included a safetyagreement on admission and agroup-walk initiative throughoutthe hospital stay, aimed at moti-vating patient participation. The

safety agreement addressed pa-tient concerns and fall-risk edu-cation; patients were asked tosign it, further encouraging theiractive participation. The initia-tive included three 6-metergroup walks daily at a self-setpace.

Since program inception, fallson this unit have decreased ap-proximately 25% and patients’mobility has increased; no fall-related injuries have occurred.About 75% of patients partici-pate in daily walks.

Academic medical center’s rehab unitThe unit’s interdisciplinary teamwas concerned about the num-ber of fall-related patient in-juries, but wanted to stay trueto the goals of the rehab unit—helping patients regain theirprehospitalization functionallevel and reducing overall func-tional impairment. As part of itsEBP, the team analyzed the re-habilitation and geriatric litera-ture for solutions related to fallsprevention.

Their work led the team todevelop a 1-page educationaltool that targeted patientsdeemed unlikely to ask for helpambulating. These patients andtheir family members wereasked to sign an agreementinviting patients to call for helpwhen they needed to get out ofbed, go to the bathroom in ahurry, reach for objects whilesitting or lying in bed, or usingassistive equipment. In return,staff promised to make roundsevery 30 minutes to anticipatepatients’ needs and to answerrequests for assistance immedi-ately. Staff were empowered touse the agreement to teach pa-tients and families about safety.The staff-patient partnership and

individualization of care haveled to a significant reduction infalls with injuries on this unit.

EBP promotes positiveoutcomesOutcomes achieved with bothprojects demonstrate that combin-ing specific actions in an interdis-ciplinary environment can reducefalls and fall-related injuries. Bothunits continue to work within their organizations to roll theirsuccesses forward to other units,following the pattern of the IowaModel. These initiatives illustratehow an EBP model can improvepatient safety and the patient ex-perience. •

Sharon Stahl Wexler is an associate professor at PaceUniversity College of Health Professions, LienhardSchool of Nursing, in New York, NY. Catherine O’NeillD’Amico is the director of Education, Research, andMagnet Project at Mt. Sinai Beth Israel’s BeatriceRenfield Division of Nursing Education and Researchin New York, NY.

Selected referencesAssociation of Rehabilitation Nurses. TheSpecialty Practice of Rehabilitation Nursing:A Core Curriculum. 6th ed. Glenview, IL: Association of Rehabilitation Nurses; 2015.

Centers for Disease Control and Prevention.Falls among older adults: An overview. Lastupdated March 19, 2015. www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html.

Hill AM, Etherton-Beer C, Haines TP. Tai-lored education for older patients to facilitateengagement in falls prevention strategies af-ter hospital discharge—a pilot randomizedcontrolled trial. PLoS ONE. 2013;8(5):1-11.

Panel on Prevention of Falls in Older Per-sons, American Geriatrics Society and BritishGeriatrics Society. Summary of the UpdatedAmerican Geriatrics Society/British GeriatricsSociety clinical practice guideline for preven-tion of falls in older persons. J Am GeriatrSoc. 2011;59(1):148-57.

Titler MG, Kleiber C, Steelman VJ, et al. TheIowa model of evidence-based practice topromote quality care. Crit Care Nurs ClinNorth Am. 2001;13(4):497-509.

Zavotsky K, Hussey J, Easter K, IncalcaterraE. Fall safety agreement: a new twist on ed-ucation in the hospitalized older adult. ClinNurse Spec. 2014;28(3):168-72.

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hile falls preventionhas become standardin inpatient care, in-

jury prevention has gotten less at-tention, both in research and every-day practice. Injuries from falls canhave serious consequences in pa-tients, ranging from minor cuts andbruises to fractures, head injury,and even death. An estimated11,000 patients die from falls in U.S.hospitals every year.

Injurious falls were deemed ahealthcare-acquired condition(HAC) by the 2005 Deficit Reduc-tion Act, and hospitals no longerreceive reimbursement for treatinginjuries resulting from falls occur-ring during hospitalization. The av-erage cost of treating injurious fallsranges from $24,000 to $27,000.

More recently, the AffordableCare Act led to changes in reim-bursement models. These modelsfactor in the occurrence of HACs,including injurious falls, to incen-tivize hospitals to improve patientoutcomes. According to currentprojections, the annual financialburden of injurious falls will reach$47 billion by 2020.

Regulatory standards requirehospitals to provide fall-preventionprograms to patients at risk offalling. While these programs in-clude care plans and protocols forpreventing falls, they may fail toprovide specific guidance or inter-ventions for preventing injuriesfrom falls.

Injury-prevention strategies anddevicesDon’t confuse fall-prevention strate-gies and devices with injury-pre-vention strategies and devices. Bedand chair alarms, lap belts, gaitbelts, chair wedges, and nonslipfootwear are designed to preventfalls, not fall-related injuries. Injury-prevention interventions are criticalcomponents of high-quality care.They include the use of material re-sources, such as floor matting orcompliant flooring, hip protectors,low-low beds, and helmets or pro-tective caps.

Special flooringCompliant flooring and floor mat-ting provide a cushioned surfacethat reduces impact, decreasing thelikelihood of injury if the patientfalls. Compliant flooring gives un-der pressure. This concept is rela-tively new and still uncommon ininpatient care settings.

Floor matting, on the other hand,has been used in practice for severalyears. A mechanical engineeringstudy of floor matting showed it re-duced injury by as much as 99%.Floor matting has several advantages:• It offers protection from both

fractures and head injury. • It’s relatively inexpensive—usual-

ly less than $150.• It’s reusable and easily cleaned

between patient uses.• It’s portable, transitioning from

the bedside to placement in frontof chairs or other areas when pa-tients are mobilized out of bed. Beveled matting is preferred be-

cause it’s less likely to pose a trip-ping hazard for nursing staff. Fold-ing mats are preferred if storagespace is scarce. (See Flooring thathelps prevent injuries.)

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Preventing injuriesfrom patient falls

Learn tips for averting injuries after a fall.

By Amy L. Hester, PhD, RN, BC

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A beveled floor mat absorbs shock and can decrease impact significantly if a pa-tient falls. Some mats, such as the one shown here, have luminescent strips onthree sides, making it easier for nurses (and patients) to see them in the dark.

Flooring that helps prevent injuries



To usefloor mattingeffectively,staff must un-derstand itshould beplaced onlywhen the pa-tient is left unattended.When staffmembers areworking ac-tively with thepatient or thepatient is be-ing mobilizedby staff, mat-ting should be taken up and placedto the side.

Hip protectorsHip protectors reduce impact fromfalls that could cause hip fracture.Available in briefs or pant-type op-tions, these garments have protec-tive pads or cushions around thelateral hip areas. They can be par-ticularly effective for frail patientsand those who have a degenerativebone disease or a low body massindex. They are inexpensive andcan be stored easily in supplyrooms. Although hip protectors arefor single patient use, the patientcan continue to wear themthroughout care transitions, includ-ing discharge to the home. (SeeProtection against hip fractures.)

Low-low beds Low-low beds keep the patient as

low to theground aspossible, re-ducing impactif he or shefalls from thebed. Manyhealthcare or-ganizationsuse thesebeds on arental basis,althoughowning themis becomingmore preva-lent. Be awarethat low-low

beds offer injury protection only ifthe patient falls directly from thebed.

Staff requires education to learnhow to use these beds properly.When the bed is positioned all theway down, patients who are weak(especially in the quadriceps) mayhave trouble getting out of bedsafely. Low-low beds should beraised to the appropriate height foreach patient to allow safe transitionout of bed.

Helmets and protective capsHelmets and protective caps protectthe head from impact during a fall.Several varieties are available, rang-ing from full head–hard shell hel-mets to vented foam helmets tocaps with protective impact poly-mers. Cost varies by type, rangingfrom about $35 to $150.

These devices typically are for

single-patient use. Like hip protec-tors, helmets travel well with thepatient throughout care transitions.Helmets and protective caps canbe particularly useful and effectivein patients at risk for head bleedssecondary to coagulopathies. Headprotection should be a seriousconsideration in patients who arereceiving anticoagulants or haveliver disease, elevated partialthromboplastin times, or lowplatelet counts secondary to onco-logic therapies.

Right resource, right patient,right timeKnowing the purpose of each mate-rial resource and when and how touse it is crucial to implement thesedevices effectively in preventing andmanaging falls and injuries. Routineinservice education from vendorsand standardized orientation of newstaff to all devices used in patientcare can improve compliance intheir use. To standardize implemen-tation of these resources, healthcareorganizations should provide clinicaldecision support through care plansand protocols that address when touse appropriate material resources.Providing the right resource to theright patient at the right time is criti-cally important. •

Amy L. Hester is director of nursing research andinnovation at the University of Arkansas for MedicalSciences Medical Center in Little Rock, Arkansas.

Selected referencesBowers B, Lloyd J, Lee W, Powell-Cope G,Baptiste A. Biomechanical evaluation of in-jury severity associated with patient fallsfrom bed. Rehabil Nurs. 2008;33(6):253-9.

Currie L. Chapter 10: Fall and injury preven-tion. In: Hughes RG, ed. Patient Safety andQuality: An Evidence-based Handbook forNurses. Rockville, MD: Agency for Health-care Research and Quality; 2008. http://archive.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/CurrieL_FIP.pdf

Wu S, Keeler EB, Rubenstein LZ, MaglioneMA, Shekelle PG. A cost-effectiveness analysisof a proposed national falls prevention pro-gram. Clin Geriatr Med. 2010;26(4):751-66.

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For patients at risk for hip fracture or falling, a hip protector like the one shownhere absorbs impact to help prevent injury. The soft foam pads are removable andwashable.

Protection against hip fractures

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• Create the right environment.• Use evidence-based practice.• Engage staff and patients.• Measure outcomes.

ollow the signposts from 1 to 4 to prevent falls.

A roadmap to effective fallsprevention

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• Identify patients at risk.• Consider risk factors for

anticipated physiologic falls,unanticipated physiologic falls, and accidental falls.

• Screen all patients for injury risk and fall-related injury history.

• Take fall precautions.• Provide a safe environment.• Address physiologic factors, such as impaired

vision.

• Prevent injuries.• Consider using floor mats, beds, and

such protective devices as helmets.


www.AmericanNurseToday.com July 2015 American Nurse Today 39com J A 5

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Resources

Three key resources for preventingfalls and protecting patients frominjuries:

Agency for HealthcareResearch and Quality.

Preventing falls in hospitals: a toolkitfor improving quality of care. 2013.www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

Boushon B, Nielsen G,Quigley P, et al.

Transforming Care at the BedsideHow-to Guide: Reducing PatientInjuries from Falls. Cambridge, MA:Institute for HealthcareImprovement; 2012.www.safetyandquality.health.wa.gov.au/docs/squire/IHI%20Guide_Reducing_Patient_Injuries_from_Falls.pdf

U.S. Department ofVeterans Affairs. VA

National Center for Patient Safety.Falls Toolkit. 2014.www.patientsafety.va.gov/professionals/onthejob/falls.asp

Fast facts

In the next 20 minutes,

an older adult will die from injuries

caused by a fall.

Causes of tramatic braininjuries in children (0 to 14 years)

Causes of hip fractures

In the next 13 seconds,

an older adult will be treated in a hospital

emergency department for injuries related to

a fall.

Unintentional falls are the leading cause of

nonfatal injuries treated in emergency departments for

all age groups except ages 10-14 and 15-24.

For those age groups, falls came in second.

55% falls

45%other

95% falls

5%other

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