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Healthcare professionals struggle with ways to improve fall safety, but getting providers to share patient safety experiences, processes and issues is a real challenge. To address this need, ECRI Institute PSO established a protected setting to learn from each other in an interactive, conversational way. Efforts to prevent patient falls were discussed among 14 participating hospitals.


ECRI Institute PSO convened a safe-table event where the hospitals could freely discuss struggles and initiatives to reduce falls and prevent injuries. The safe-table environment provides confidentiality and legal protection from disclosure. Safe tables are a core feature of most ECRI Institute PSO memberships. ECRI Institute PSO experts facilitated the discussion, providing evidence-based analysis and feedback.

All participants expressed a need to improve fall safety. Participants talked about patients disconnecting bed alarms, or bed alarms that did not work. Some discussion focused on special provisions needed for behavioral health patients or postsurgical patients, who are often still groggy when returning to their room.

Participants discussed recurring situations where fall risk may increase, such as when a patient is toileting or is tethered by intravenous (IV) lines. One hospital shared their results from implementing a rule that no patient may be left alone in the bathroom; staff will even keep the door ajar to allow easier access while providing as much privacy as possible. For falls attributed to tripping over IV lines, suggestions focused on how to secure the lines closer to the bed rather than letting them hang.

Another hospital implemented a “Do Not Pass" protocol, where any staff should respond if they hear a call bell or see a patient doing something risky. Sometimes, all a patient needs is help reaching an item in a purse or bedside tableany staff member can assist.

Participants also learned from a hospital that recently implemented a remote video monitoring system. The system can be used to communicate with the patient from a centralized monitoring room to prevent him or her from doing something that may result in a fall.


Participants in the safe table shared their successes and challenges with one another and benefitted from learning what has worked and not worked for other hospitals. The participants were able to share new initiatives being piloted and efforts made to decrease fall rates.

The discussions were successful in supporting shared learning and in helping providers improve their own falls initiatives without the risk of the information being used against them.


Learn more about ECRI Institute PSO membership.