Falls are a high-volume, high-risk, high-cost challenge for healthcare facilities worldwide. In addition to the serious injuries and costs associated with falls, hospitals risk financial consequences if they do not have measures in place to prevent patient falls.
In October 2008, Medicare stopped reimbursing U.S. hospitals for the treatment of falls injuries occurring during patients' stays if the falls were considered preventable. Other third-party payers have followed the Medicare program's initiative and will no longer pay for certain hospital-acquired, preventable injuries such as those related to some falls.
Although falls management programs are in place in many healthcare facilities, healthcare risk managers must ensure that these programs are followed and are effective in preventing falls and injuries related to falls.
Healthcare Risk Control (HRC) recommends that risk managers implement comprehensive falls management programs in all types of healthcare settings. This article provides risk managers with guidance in the following:
- Understanding Centers for Medicare and Medicaid Services (CMS) regulations and Joint Commission falls assessment and prevention requirements
- Understanding the breadth of factors that may cause or contribute to falls
- Developing an interdisciplinary falls team
- Identifying patients at risk for falls
- Preventing falls
- Responding to falls
Several tools for a falls management program are provided on the
HRC members' website. Several tools for a falls management program are provided on the
HRC website. See
Resource List for a complete list, and look for resources highlighted throughout this guidance article.
Facts about Falls
Falls are common, particularly for older adults, both in the community and in healthcare settings. The Centers for Disease Control and Prevention (CDC) estimates that one in three U.S. adults age 65 or older falls each year (CDC "Important Facts About Falls"). According to the Joint Commission, hundreds of thousands of patients fall in hospitals each year, with 30% to 50% of falls resulting in injury (Joint Commission "Sentinel Event Alert"). The Agency for Healthcare Research and Quality (AHRQ) states that between 700,000 and 1,000,000 people fall in the hospital each year (AHRQ). Other studies estimate that 3% to 20% of hospital inpatients fall during a hospital stay (AAOS). According to the U.S. Department of Veterans Affairs' (VA) National Center for Patient Safety (NCPS), an internal, confidential, nonpunitive reporting system, falls represented the number one category of root-cause analyses as of March 2015 (U.S. VA). Between 50% and 75% of nursing home residents fall each year—twice the rate among older adults in the community (CDC "Falls in Nursing Homes").
In its September 28, 2015, Sentinel Event Alert on preventing falls and fall-related injuries in healthcare facilities, the Joint Commission identified the most common contributing factors to falls with injuries. They were as follows (Joint Commission "Sentinel Event Alert"):
- Inadequate assessment
- Communication failures
- Lack of adherence to protocols and safety practices
- Inadequate staff orientation, supervision, staffing levels, or skill mix
- Deficiencies in the physical environment
- Lack of leadership
Injuries sustained from a fall can be life-threatening. Falls are the leading cause of death from unintentional injuries among U.S. adults age 65 or older, according to CDC data. In 2012 and 2013, nearly 50,000 U.S. adults age 65 or older died from injuries related to unintentional falls—representing 55% of all unintentional deaths in this age group (as opposed to intentional deaths, which can be caused by suicide or homicide). (Kramarow et al.)
The Joint Commission states that falls involving serious injury consistently rank among the top 10 sentinel events reported to the agency. Between 2009 and 2015, the Joint Commission received 465 reports of falls with injuries; the majority of these falls occurred in hospitals, and about 63% resulted in death. (Joint Commission "Sentinel Event Alert") Falls were also the second-most frequent category of sentinel events reported to the Joint Commission in 2014. (U.S. VA)
A fall may result in fractures, lacerations, head injury, or internal bleeding. Hip fractures are one of the most common types of serious injury sustained as a result of a fall. A 2010 study found that, of 758 patients over the age of 60 who sustained hip fractures between April 15, 2005, and March 1, 2009, 21.2% died within one year (Schnell et al.)
A total of 33,253 falls-related events were reported in 2014 to the Pennsylvania Patient Safety Authority's web-based Pennsylvania Patient Safety Reporting System (PA-PSRS), an independent state agency. Of these, 3% (928) were classified as serious events, and no injury was associated with 32,325 of the falls. (PA-PSRS "2014 Annual Report")
Falls-related injuries are associated with significant healthcare costs. According to CDC, the direct medical costs for fall injuries for U.S. patients ages 65 or older are $34 billion annually, with hospital costs accounting for two-thirds of the total. (CDC "Important Facts about Falls"). The Joint Commission states that the average cost for a fall with injury is $14,000. ("Sentinel Event Alert")
Claims related to falls are generally high in frequency and low in severity. A snapshot of claims related to falls is provided by Aon Corporation's 2011 Hospital Professional Liability and Physician Liability Benchmark Analysis. In its 2011 report, Aon found that five healthcare-acquired conditions—healthcare-acquired infections, healthcare-acquired injuries (which includes falls), medication errors, retention of objects after surgery, and pressure ulcers—account for one in four closed claims, or 25% of total hospital professional liability costs. Claims related to falls accounted for the bulk of healthcare-acquired injuries, which include fractures, dislocations, intracranial and crushing injuries, and burns. Healthcare-acquired injuries were the most frequently occurring claims for healthcare-acquired conditions. (Aon Corporation)
Recent claims data on falls from long-term care settings may also be useful for hospitals. Falls-related claims in long-term care facilities were the most frequent allegations: of 2,401 closed claims occurring in 2012 and 2014, 991 (41%) involved resident falls, according to a study by CNA HealthPro in Chicago, a national insurance company for healthcare facilities. In 2012 and 2014, resident falls represented 46.6% and 46.3%, respectively, of closed claims for assisted living facilities. Combined data for 2012 and 2014 shows that, of injuries associated with resident falls, 47.9% resulted in fractures and 40.4% resulted in death. The cost to settle a falls claim tends to be lower than average, although the overall costs associated with resident falls are considerable in light of the frequency of these events. (CNA HealthPro)
Patients and family members often perceive falls as preventable occurrences that indicate less-than-optimal quality of care. The willingness of the public to punish facilities that do not protect patients and residents from falling is highlighted by a 2012 Virginia jury award of $3.5 million against a hospital. After undergoing hip arthroplasty, the patient was initially evaluated as a "high" fall risk—owing to age, mobility problems, and various prescribed medications she was taking—and required prevention interventions. During recovery, the patient attempted to get out of bed and slipped, fracturing her femur and necessitating a second surgery. The patient also sustained a mild head injury that allegedly led to a stroke. Following the fall, the plaintiff sued, alleging negligence on the part of a nurse and the facility in contributing to the fall and causing significant injuries. The plaintiff claimed that the morning nurse did not complete the falls risk assessment documentation, administered a narcotic, and did not implement any falls management interventions. (Burrell v. Riverside Hospital)
However, not all patient falls are considered the result of negligent care. In
Lewandowski v. Mercy Memorial, a nurse helping a patient resume daily activities such as sitting in a chair, getting out of bed, and learning how to move with a walker was found not liable for a fall that the patient sustained as the nurse was helping to dress her. In 2003, the court found that the nurse was performing a "professional nursing intervention" when she helped the patient in these activities and that an expert witness testifying to a breach of standard of care was required. No expert was brought forth, and the case was dismissed. ("Patient Falls")
In October 2008, CMS stopped reimbursing for care resulting from injuries sustained from in-hospital falls if the fall could have been prevented during the Medicare beneficiary's stay (CMS "Medicare Program"). The provisions apply to hospitals receiving Medicare payments under the Inpatient Prospective Payment System (IPPS). The provisions do not apply to hospitals such as critical access hospitals, cancer facilities, and children's hospitals that are exempt from IPPS. CMS has indicated, however, that it may extend some aspects of its initiative to hospital outpatient and ambulatory surgical settings.
CMS classifies falls and trauma (resulting in fractures, dislocations, intracranial injuries, crushing injuries, burns, and other injuries) as one of the 14 hospital-acquired conditions deemed to be reasonably preventable if clinicians follow evidence-based guidelines to prevent the injury or condition. CMS selected the various hospital-acquired conditions because they are either high cost and/or high volume and result in a higher payment when submitted as a secondary diagnosis. (CDC "Hospital-Acquired Conditions") CMS further specifies that the no-payment provision for hospital-acquired injuries and conditions applies if the condition was absent on admission but occurred during the patient's hospital stay. Therefore, if a Medicare beneficiary is injured in an in-hospital fall, the Medicare program will not cover the hospital's cost to treat the injury.
Although criteria for identifying hospital-acquired conditions include the availability of evidence-based prevention guidelines, CMS does not identify specific prevention guidelines for hospitals to consider in the case of falls. Several falls management guidelines are referenced in this guidance article; information on accessing the guidelines is available in
Although some have argued that not all falls in hospitals are preventable, CMS disagrees and says that a hospital-acquired condition such as falls "could reasonably have been prevented through the application of evidence-based guidelines." (CMS "Hospital Inpatient," 2014). An exception to the no-payment policy is for more than one secondary diagnosis associated with the claim—when the additional diagnosis is not associated with a hospital-acquired condition. In this situation, the claim is reimbursed at the higher rate to treat the secondary diagnosis.
CMS has identified certain diagnosis codes for fractures, dislocations, intracranial injuries, crushing injuries, and burns that could result from a fall or trauma. If the codes are not present on admission but are later added to reflect the patient's condition during the hospital stay, CMS will conclude that the condition was acquired in the hospital as a result of a fall or trauma. CMS would not pay the additional amount to treat the particular hospital-acquired injury because the fall or other type of trauma was preventable, CMS reasons.
Other CMS Requirements
Other CMS regulations broadly address falls management as part of a healthcare facility's safety program. Medicare Conditions of Participation, for example, state that hospital patients have "the right to receive care in a safe setting" (42 CFR § 482.13[c]). Similarly, Medicare requirements for long-term care facilities state that the "resident environment [must remain] as free of accident hazards as is possible" (42 CFR § 483.25[h]) and that each long-term care resident must "receive adequate supervision and assistance devices to prevent accidents" (42 CFR § 483.25[h]).
CMS Monetary Penalties
Facilities also risk incurring CMS monetary penalties for failing to provide safe environments for patients and residents. In the September 2006 appeals case
Bethel Center v. CMS, the U.S. Department of Health and Human Services Departmental Appeals Board upheld a ruling that found a Wisconsin skilled nursing facility in violation of 42 CFR § 483.25(h)(2). This regulation requires that facilities take reasonable steps to supervise residents and provide assistive devices to meet assessed needs in addition to providing appropriate plans of care. The appeals board found that the facility failed to properly assess residents for their risk of falling, failed to adequately supervise residents at extreme risk for injuries from falls, and failed to assess its residents after falls. The facility's noncompliance caused serious harm to some residents and had the potential to cause harm to others, the appeals board said. The monetary penalty imposed by CMS of $6,000 per day for a four-day period and $100 per day for the following month was reasonable given that the facility's deficiencies "were very serious," the decision said. (Bethel Center v. CMS)
In another case,
Ben Hur Home v. CMS, the appeals board found in June 2006 that an Indiana skilled nursing facility failed to adequately assess its residents after falls to determine how to prevent the falls and failed to implement prevention measures it determined were necessary. Additionally, the facility had too few staff members to adequately supervise its residents, the decision said, noting that one resident who fell 35 times in one year was not receiving adequate supervision. The decision upheld CMS's total monetary penalty of $145,000 against the facility. (Ben Hur v. CMS)
The Joint Commission
Patient falls involving death or serious injury are defined by the Joint Commission as sentinel events. The Joint Commission requires accredited hospitals to conduct fall risk assessments for hospitalized patients to identify each patient's risk for falls so that prevention measures can be incorporated into the plan of care.
For 2015, the Joint Commission, as part of its National Patient Safety Goals (NSPG), requires that home care, nursing centers, and long-term care providers reduce the risks of patient and resident harm resulting from falls. (Joint Commission "2015 National Patient Safety Goals"). Falls management is also addressed in the Joint Commission's standards—for example, falls management is covered in the chapter "Provision of Care, Treatment, and Services," which requires facilities to assess and manage the patient's risks for falls. (Joint Commission, "Comprehensive")
On September 28, 2015, the Joint Commission released a Sentinel Event Alert on preventing falls and fall-related injuries in healthcare facilities. In the alert, the Joint Commission recommends that the following steps be taken to help healthcare facilities reduce the risk of falls (Joint Commission "Sentinel Event Alert"):
- Lead an effort to raise awareness of the need to prevent falls resulting in injury.
- Establish an interdisciplinary falls injury prevention team or evaluate the membership of the team in place.
- Use a standardized, validated tool to identify risk factors for falls.
- Develop an individualized plan of care based on identified fall injury risks, and implement interventions specific to a patient, population, or setting.
- Standardize and apply practices and interventions demonstrated to be effective, including a standardized hand-off communication process and one-to-one education of each patient at the bedside.
- Conduct postfall management, which includes a postfall "huddle"; a system of honest, transparent reporting; trending and analysis of falls, which can inform improvement efforts; and reassessment of the patient.
DNV GL (Det Norske Veritas Germanischer Lloyd) requires facilities to measure, monitor, and analyze threats to patient safety, including falls. Falls should also be considered when developing plans of care. The standards also address the use of restraints and siderails; according to DNV, "devices that protect the patient from falling out of bed are not restraints. However, [if all four side rails are raised] in order to restrain a patient (as this may immobilize or reduce the ability of a patient to move his or her arms, legs, body, or head freely) to ensure the immediate physical safety of the patient then the rule applies. A patient's history of falls without current evidence of falling is not a reason to use restraints." (DNV GL) For more information, see
Reduced Use of Restraints.
National Quality Forum's Serious Reportable Events
The National Quality Forum (NQF) lists falls in healthcare facilities that result in patient death or serious injury as one of its serious reportable events. Numerous states have adopted NQF's list or a variation of the list in their requirements that licensed healthcare facilities report serious events, and many of the hospital-acquired conditions under the CMS initiative are also on the NQF list.
For example, in 2003, Minnesota became the first state to require licensed healthcare facilities to report events from the entire NQF list. As of 2014, 8 states have adopted or adapted the NQF list, and an additional 7 use a modified or adapted version of the list; 12 states use their own state-developed lists (National Academy for State Health Policy). See
U.S. State Adverse Event Reporting Systems. Some private payers have similar provisions in place, including HealthPartners, Cigna, Blue Cross, Aetna, and Wellpoint (Sohn).
Develop a Falls Management Team
Action Recommendation: Create and maintain an interdisciplinary falls management team to implement, monitor, and routinely revise the falls management program using reactive analyses of falls, the facility's falls data, and a falls baseline.
Healthcare facilities should implement falls management programs to help reduce the frequency and severity of patient falls. To reduce falls rates, facilities should assemble an interdisciplinary team of practitioners and administrators to design a process to assess an individual's risk of falling and to target interventions to reduce his or her risk, with the unified goal of reducing falls within the institution.
The composition of a facility's falls team will depend on the facility's size, current falls rate, patient population, and resources. See
Composition of a Falls Team for information on who should be invited to join a falls team.
Generally, a falls team is responsible for the development, implementation, and ongoing review of falls management protocols and policies. The team is also generally responsible for reviewing all falls that occur, developing protocols to eliminate or reduce the impact of all risk factors identified in the investigation, and analyzing the efficacy of all interventions in use.
Responsibilities for falls teams include the following (Kimbell):
- Define the goals of the group and the responsibilities of each member.
- Define what constitutes a fall and a near miss based on facility experience and standardized definitions.
- Establish a falls rate baseline.
- Perform a risk assessment of the care environment.
- Select risk assessment tools to be used to establish a patient's risk for falling.
- Delineate interventions that will be used.
- Educate staff on how to perform, document, and communicate the results of risk assessments.
- Train staff on how to correctly implement appropriate interventions.
- Implement risk assessment and reassessment processes for all patients.
- Evaluate the program after the first month, then again every quarter.
- Report findings to all appropriate stakeholders and committees.
- Review falls rates, falls injury rates, and feedback from staff, patients, and family members.
- Adapt elements of the falls program based on progress and feedback over time.
One of the first tasks of the falls team should be to define what constitutes a fall or a near miss. The process of developing a falls management program requires that the facility clearly define and communicate to staff what a fall is and how the falls rate will be measured. Consistency in applying this definition is key to accurately measuring the number of falls in an institution. Some previously developed definitions of "fall" are as follows:
- A loss of upright position that results in landing on the floor, ground, or an object or furniture, or a sudden, uncontrolled, unintentional, nonpurposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or stair, excluding falls resulting from violent blows or other purposeful actions. (U.S. VA)
- An unplanned descent to the floor with or without injury to the patient, including falls when a patient lands on a surface where you wouldn't expect to find a patient. (AHRQ)
- An individual unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (such as from an individual pushing another individual) (CMS "State Operations Manual")
As suggested by all the definitions, many organizations intentionally exclude any fall that is the result of "sudden onset of paralysis, epileptic seizure, or overwhelming external force" (Tinetti et al. "Reducing the Risk"). However, it is possible to include potential falls—what can be considered near misses—as CMS does in its definition for falls; CMS states, "An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall." Additionally, an episode is counted even when there is no injury. "A fall without injury is still a fall," says CMS. (CMS "State Operations Manual")
A potential or actual fall may be defined as any occurrence in which any of the following takes place:
- A patient is found on the floor; unless evidence suggests otherwise, a fall is considered to have occurred.
- A patient slides to the floor unassisted.
- A patient rolls off a bed or chair and onto the floor.
- A patient falls off or out of any equipment or apparatus used for therapy or transfer (e.g., wheelchair, stretcher).
- A patient trips or slips and complains of or sustains bodily injury.
- A patient, visitor, or family member reports a fall.
In addition, according to a report from PA-PSRS, assisted falls—a controlled fall or slump in which the patient is assisted to the floor by a hospital employee—should be included in the hospital's definition of a fall. (Feil and Wallace)
Falls benchmarks are used to compare a facility's falls rate against an accepted standard. Falls rates that measure the actual occurrence of falls in a facility or unit are commonly expressed in terms of the number of falls that occur per 1,000 patient-days and are calculated using the
The numerator (number of patient falls) represents all falls, not all patients who have fallen, so repeat falls by the same patient would be counted as multiple falls, not just as one fall.
Another commonly used measure is the falls injury rate, to evaluate injuries for every 100 falls. Given that all falls are not equal, it is important to distinguish falls based on the severity of injuries resulting from the falls.
VA's NCPS, which has compiled a comprehensive toolkit for falls management, recommends the following severity ratings (U.S. VA):
- None: patient had no injuries (no signs or symptoms) resulting from the fall; if an x-ray, computed tomography scan, or other postfall evaluation results in a finding of no injury
- Minor: resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain, bruise, or abrasion
- Moderate: resulted in suturing, application of butterfly closures/skin glue, splinting, or muscle/joint strain
- Major: resulted in surgery, casting, or traction; required consultation for neurological (basilar skull fracture, small subdural hematoma) or internal (rib fracture, small liver laceration) injury; or (for patients with coagulopathy) received blood products as a result of a fall
- Death: the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall)
Several databases are available in which organizations can benchmark their falls data to facilities with a similar number of beds or to similar units within a facility. Such databases include the California Nursing Outcomes Coalition (CalNOC), the U.S. Department of Health and Human Services (through its Hospital Compare website), and the Pennsylvania Patient Safety Authority.
CalNOC suggests using median rates, which are less affected by outliers than other measures. Knowing that the median falls rate is a midpoint for benchmarking, some facilities set goals to be better performers, using targets that are lower than the median falls rate. (Aydin)
On a national scale, the National Database of Nursing Quality Indicators, a proprietary database of the American Nurses Association, provides patient falls and falls injury rates for its participants. CMS also reports on falls with trauma that occur in Medicare-participating hospitals.
In published studies, researchers and individual organizations have reported various falls rates. For example, a 2004 study reported falls among hospital inpatients ranging from 2.3 to 7 falls per 1,000 patient-days (Hitcho et al.). In 2002, Barnes-Jewish Hospital (St. Louis, Missouri) reported a hospital-wide fall rate of 3.29 per 1,000 patient-days (Krauss et al.). Another study analyzed falls rate data from 2009 that was reported to CalNOC. The data was derived from 789 medical-surgical units in 215 participating California, Oregon, and Washington hospitals. In 2009, CalNOC reported mean falls rates for medical-surgical units as 3.21 falls per 1,000 patient-days. (Aydin) However, these falls rates are not meaningful if a facility's data is not risk-adjusted in the same way as the mentioned falls rates. The organization's definition of a fall, reporting policies, and method of calculating falls rates (falls per bed, per patient, per patient-day, or per patient-year) must be considered. Population mix and type of care unit must be considered as well so that the organization is using comparable populations—such as acute, behavioral, rehabilitation, or geriatric—for comparison.
To avoid comparing facility falls rates to a falls rate benchmark that does not represent the facility's risk factors, facilities should benchmark against their own baseline by developing falls rate targets using the facility's data on past falls. Comparing the facility's data will also provide valuable information on trends (see the discussion
Monitoring a Program's Effectiveness).
Establish a Falls Management Policy
Action Recommendation: Develop, implement, and routinely update all falls management policies, protocols, and risk assessment and reassessment tools.
Action Recommendation: Develop and implement initial and ongoing falls management education programs for professional staff, clinical personnel, volunteers, and nonclinical facility employees, including education on conducting a thorough risk assessment, implementing proper interventions, responding appropriately to falls, and correctly filing event reports.
Establishing Policies and Protocols
Risk managers must ensure that falls policies are developed and that nurses, other clinical and nonclinical employees, and volunteers—as well as medical staff and students—are aware of and follow the policies. In the event of a fall, healthcare facilities that do not have written policies could be found liable for failure to establish policies for patient safety.
When developing or revising falls management policies and protocols, it is important to remember that the risk factors for falls are multifaceted and that no single type of intervention will succeed in eliminating the risk of falling. Major areas that should be addressed in a falls management policy include the following (U.S. VA; Hakim):
- Composition, responsibilities, and goals of a falls team
- Definition of a fall and near miss (e.g., trip, slip, stumble)
- Falls risk assessment requirements for inpatients, outpatients, visitors, and employees
- Requirements for reassessment of risk
- Environment-of-care assessments to identify factors likely to contribute to falls
- Responsibilities of staff
- Initial and ongoing education of clinical and nonclinical staff
- Intervention strategies (including the use of equipment to prevent falls
- Appropriate responses to falls, including protocols for investigation
- Event documentation and reporting requirements
- Collection and review of data for trends
- Revision of intervention strategies based on data
- Falls rates reporting within a quality improvement plan
- Promotion of the falls management program and risk awareness
In addition, staff member noncompliance with falls policies, procedures, and protocols may indicate systems issues and should trigger further analysis.
Facilities can access a sample falls policy from the VA falls toolkit developed by NCPS. See
Resource List for further information on accessing the NCPS website.
Assess an Individual's Risk Factors
Action Recommendation: Ensure that patients are assessed and/or reassessed on admission, when their physical condition changes, when they are transferred to another level of care, and when a fall or near miss occurs, and ensure that residents are also reassessed on a quarterly basis.
To determine whether individuals are at risk for falling, facilities must conduct a falls risk assessment on each individual, evaluating both intrinsic and extrinsic factors. Intrinsic factors indicate the patient's medical, psychological, and physical issues, such as medications, fear of falling, or muscle strength. Extrinsic factors address the environmental risks that patients encounter, such as slippery floors or inadequate staffing. (See
Intrinsic and Extrinsic Risk Factors.)
- Age greater than 65 years
- History of falls
- Incontinence or urinary frequency or urgency
- Lower-extremity weakness
- Gait and balance deficits
- Use of tranquilizers, sedative-hypnotic drugs, or antihypertensive drugs*
- Use of four or more prescription drugs
- Postural or orthostatic hypotension
- Reduced visual acuity
- Slowing darkness adaptation
- Perceptual changes (e.g., inability to perceive depth, reduced contrast sensitivity)
- Loss of hearing
- Proprioceptive dysfunction
- Degenerative disorders of the spine
- Functional impairment (e.g., inability to perform basic activities of daily living)
- Changes in mental status, including dementia and depression
- Foot disorders
- Poor impulse control
- Belief that asking for help is inappropriate
* While many sources consider medication use an intrinsic factor, some facilities may view administration of medication as an extrinsic factor.
- Bathroom designs that do not include handrails or raised toilets
- Pieces of furniture, such as tables, beds, and chairs, that are on wheels and have sharp edges
- Flooring that is highly polished, wet, or covered with loose carpeting or throw rugs
- Ill-fitting or inappropriate shoes (e.g., shoes with high heels or rubber crepe soles that stick to flooring) or clothing (e.g., long gowns, loose-fitting clothing)
- Incorrect assistive device for physical deficit (e.g., patient has borrowed a neighbor's cane)
- Maintenance of assistive devices (e.g., wheelchairs, support poles, trapezes)
- Instruction on use of assistive devices
- Nurse staffing levels or staffing mix
- Time of day (increased risk during shift changes or early morning hours)
- Prolonged length of stay
- Bed in high position
- Toilet in low position
- Use of restraints
- Full-length bedrails
- Monochromatic color schemes or distracting colors
- Distracting noises
- Communication between staff, patient, and family
- Staff training and education
- Attachment to equipment such as heart monitors or
Sources: U.S. Centers for Disease Control and Prevention.
Risk factors for falls [online]. 2015 Sep 8 [cited 2015 Oct 26].; U.S. Department of Veterans Affairs.
Background. In: National Center for Patient Safety. Falls toolkit [online]. 2004 May [cited 2008 Nov 24].; National Council on the Aging.
Falls free: promoting a national falls prevention action plan. Washington (DC): NCOA; 2005.; Nagourney E.
Aging: a new culprit in nighttime falls [online]. NY Times 2005 Apr 12 [cited 2015 Oct 26].; Ward A, Candela L, Mahoney J.
Developing a unit-specific falls reduction program.
J Healthc Qual 2004 Mar-Apr;26(2):36-40.
Because risk factors can change suddenly, patients and residents should be assessed at the following times:
- On admission
- When physical condition changes (e.g., medications given, surgery, return from physical therapy)
- When a fall or near miss occurs
- When transferred to a new unit or level of care
- As required by state and federal regulations
Constraints on staff time require the use of tools that address as many risk factors as are practical and still effective. Because different assessment tools may be appropriate for different patient populations (e.g., nursing home versus acute care populations), facilities that use standardized risk assessments, such as the Morse, Hendrich, or Tinetti scales, should review and modify these assessments to appropriately assess their particular patient population's risk factors before implementation. Guidance in the form of staff suggestions, findings from reactive analyses for past patient falls, and unit demographics will help falls teams develop and revise effective assessment tools.
Risk assessments are formatted in numerous ways, and many hospitals use a point system to identify falls risk. For example, a risk assessment form may include an evaluation of risks posed by an individual's visual acuity, with a score of 0 indicating that no risk is posed by this factor and a score of 4 indicating that this factor poses a high risk. The scores are totaled and compared to a risk scale differentiating between patients at risk, high risk, and very high risk for falling. When selecting or developing a risk assessment tool, facilities are advised to ensure that the scores accurately differentiate risk levels. For example, if the scoring tool indicates that all patients are very high risk, caregivers will not perceive the tool as a credible indicator.
Hendrich II Fall Risk Assessment, a purposefully brief and statistically validated test to predict falls risk using eight intrinsic factors, such as prescribed medications and patient confusion; any patient with a score of 5 or greater is considered at high risk for falls (Hendrich et al.). The assessment can be completed in less than a minute.
Assessments in physician practice settings. Risk managers at facilities that manage or oversee physician practices should ensure that their practices are assessing patients for falls risk. One study demonstrated that when clinicians in primary care settings are provided information about falls risk assessment and strategies to prevent falls, they can make a positive impact in reducing falls-related injuries in older adults (Tinetti et al. "Effect"). CMS encourages physicians to conduct falls risk assessments by including falls assessment of patients age 65 or older as one of the quality measures for its voluntary Physician Quality Reporting Initiative (CMS "Physician Quality").
Review Medication Regimens
Action Recommendation: Ensure that pharmacists review medication regimens and communicate to physicians the benefits of reducing or eliminating drugs that can increase the risk of falling.
Administration of certain prescription and nonprescription medications increases the risk of falling. Patients taking multiple medications are also at increased risk of falling. Medications that increase a patient's risk of falling include the following:
- Nonsteroidal anti-inflammatory agents
- Oral hypoglycemics and insulin
- Serotonin reuptake inhibitors
- Tricyclic antidepressants
Sources: Tinetti M. Preventing falls in elderly persons. N Engl J Med 2003 Jan 2;348(1):42-9. Also available at PubMed; National Council on Aging (NCOA).
Falls free: promoting a national falls prevention action plan. Washington (DC): NCOA; 2005.
One of the most common medication side effects is an increased risk of falling (Tinetti). For example, 21% of patient falls reports submitted to a state reporting system list medication as a contributing risk factor in a 2008 report (Pennsylvania Patient Safety Authority "Medications Contributing"). Medication classes strongly linked to an increased risk of falling include antihypertensive agents, diuretics, β blockers, sedatives and hypnotics, neuroleptics and antipsychotics, antidepressants, benzodiazepines, narcotics and nonsteroidal anti-inflammatory drugs (de Jong et al.) They can cause changes in cognitive and physical function, changes in blood pressure, dizziness, balance difficulties, confusion, and sedation—all of which increase the risk of falls. (See
Medications That Increase the Risk of Falling.) An individual's risk of falling also increases when he or she is taking multiple drugs simultaneously. (Tinetti)
Because of the high correlation between falls and medication use, facilities are advised to request that pharmacy staff provide an ongoing review of patient medication regimens (Pennsylvania Patient Safety Authority "Medication Assessment"). The pharmacist can identify opportunities to reduce the medication dose, discontinue the medication, or substitute an alternate drug with less falls risk potential. Studies suggest that many healthcare facilities enlist pharmacy review of medications only after a patient falls or is identified as being at high risk of falling (Pennsylvania Patient Safety Authority "Medication Assessment"). Ideally, pharmacist review should start with the initial falls assessment and continue with every medication order.
Some healthcare systems have developed a list of medications that increase an individual's risk of falling and identified strategies to alert caregivers when one or more of these medications is prescribed. For example, as part of a more comprehensive falls management program, one health system's automated medication dispensing cabinet alerts caregivers when one of the drugs selected increases a person's risk of falling. Caregivers can then consider placing the patient on falls precautions (Pelczarski and Wallace). Organizations with computerized provider order-entry systems can also use a high-risk medication list to prompt a falls risk warning when a high-risk medication is selected (Pennsylvania Patient Safety Authority "Medication Assessment").
Incorporate Interventions and Staff Education
Action Recommendation: Provide initial and ongoing staff education on falls management strategies, including patient assessments and reassessments, falls interventions, frequent toileting and patient rounding, application of restraint reduction policies and procedures, use and maintenance of equipment (e.g., bedrails, alarms, assistive devices, restraints), and use of transfer techniques.
Action Recommendation: Ensure that the patient's risk for falling is effectively communicated to the patient and family and all clinical and nonclinical staff. Consider the use of whiteboards in nursing stations and patient rooms, as well as other mechanisms, to identify patients who are at increased risk for falls. Provide informational materials to patients and families.
Action Recommendation: Educate home care providers on home falls management techniques. Provide informational materials to ensure that home care patient and family education is taking place.
A falls management program should assess, incorporate, and reassess multiple interventions specifically targeted to the individual's case, considering the benefits and risks of maintaining the highest degree of functionality possible. Facilities must develop and implement interventions that address the specific risk factors that each patient faces. Numerous interventions are available to healthcare providers. For example, in 2008, a regional collaborative of Philadelphia-area hospitals interested in effective measures to prevent patient falls identified 60-plus mitigation strategies to prevent patients from falling or to reduce the severity of injuries caused by falls (Pelczarski and Wallace) Some of the measures that were particularly effective are listed in
Effective Interventions for Hospital Falls Management.
Approaches for implementing some of the most effective strategies are described in detail below.
Staff education is essential to the success of a falls management program. Almost 80% of organizations reporting fatal or injurious falls to the Joint Commission between 1995 and 2005 cited incomplete staff orientation and training. For example, 50% of the root-cause analyses conducted for falls reported to the Joint Commission identified incomplete assessment or reassessment as a root cause for patient falls. (ECRI Institute "Falls Prevention")
All clinical and nonclinical staff should attend a mandatory in-service program describing the purpose and goals of the falls management program. The program should be tailored to specific employee groups; for example, a program for nonclinical staff such as housekeeping will be different from the program tailored to clinicians. An education program for clinical staff should cover the following:
- Intrinsic and extrinsic causes of falls
- Instructions for conducting a complete risk assessment
- Falls management interventions (e.g., frequent toileting rounds)
- Correct transfer techniques
- Placement of high-risk patients in rooms near the nurses' station
- Use of patient lifts (also important in preventing employee back injuries)
- Use of assistive devices and aids
- Use of commodes and shower chairs
- Instructions for completing a postfalls assessment
- Hazard and incident reporting
- Postfalls education for patients
This training should be reinforced with ongoing mandatory clinics and other means such as printed materials on the facility's falls management program. Progress reports are also helpful to maintain staff enthusiasm for a falls management program.
Falls Management Training Program is one such sample training program for staff.
Communicating the Patient's Fall Risk
Communication issues were a common root cause for falls-related sentinel events between 1995 and 2005. More than 60% of organizations that reported a fatal or injurious fall to the Joint Commission cited inadequate caregiver communication as a root cause of the accident (ECRI Institute "Falls Prevention").
A more recent study examined 325 root-cause analyses from the VA NCPS to determine the most common types of adverse events occurring among older patients (age ≥65 years) in VA hospitals between January 2010 and January 2011. Falls were the most commonly reported adverse events in this population, representing 34.8% of the reports. In addition, communication was the most common underlying reason for adverse events overall, representing 43.9% of reported root causes. (Lee et al.)
In its Sentinel Event Alert on falls management, the Joint Commission recommends communication strategies such as using a standardized handoff communication process, which can include using whiteboards to communicate falls risks to staff on all shifts; incorporating alerts, tasks, records, and prompts into the patient's electronic medical record, or initiating a bedside shift report with the patient that includes falls risk concerns. (Joint Commission, "Sentinel Event Alert")
Additionally, high-risk patients must be clearly identifiable as such to nurses and other staff, including agency nurses or others working on the unit temporarily (e.g., float nurses). Ways to increase the visibility of high-risk patients include the following:
- Using standardized, color-coded arm- or wristbands
- Using indicators in the medical record, at the patient's station call light (to remind nurses to answer these patients' calls promptly and in person), or on the nursing station whiteboard listing patients on the unit
- Placing the patient near the nursing station on admission or after he or she has been assessed as high risk for falls
- Using indicators on the patient's bed or door
Visible indicators such as those used in the Falling Leaf or Falling Star programs encourage nonclinical staff members such as housekeeping, dietary, and security personnel to participate in the care of patients when they see a patient engaging in behavior likely to increase the risk of falling ("Falling Leaf"). The Falling Star program—developed by a registered nurse—involves assessing patients for risk for falling and then identifying such patients with a visible symbol. The Falling Leaf program evolved from the Falling Star program and emphasizes identifying those at highest risk for falling and conducting root-cause analyses to determine needed improvements in intervention techniques after a patient has fallen. Dietary staff will know, for example, to place a food tray close to the patient's bed so that it is easily reached. Similarly, housekeeping staff will know to place a wastebasket near the patient's bed.
When patients are moved or discharged, facilities must remember to handle the indicator appropriately (e.g., indicators should be moved with the patient or thrown away). Otherwise, all staff will quickly view indicators as unreliable and disregard them.
Facilities should note that implementing only visual indicators may be ineffective. A randomized controlled study on the efficacy of using color-coded bracelets to reduce falls did not demonstrate effectiveness and revealed that this practice might contribute to loss of function due to stigma and heightened fear of falling (Lyons).
Patient and Family Education
Facilities must provide education for both the patient and the family about the causes of falls and possible interventions. Such discussions also help to manage unrealistic expectations. A family's expectation that their loved one will never fall once admitted to the facility should be managed in a manner that shows that the facility takes safety seriously.
Some hospitals give patients information on admission that explains why falls may occur and provides guidelines on how to avoid falling while in the hospital. The information includes reminders to ask nurses for assistance and to follow physician orders regarding staying in bed. Given that patients and families will not read all the admission information they receive, it is important that this information be delivered directly to patients and families, along with direct one-on-one discussions. Some facilities may provide additional information after a patient falls to reinforce prevention strategies. These discussions should be documented in the patient's chart.
Direct discussions should include showing patients the location of the bathroom and how to use the nurse call system, which should be placed within easy reach along with other important personal items. Nurses should explain to all high-risk patients why they may be likely to fall (e.g., medications may cause dizziness, surgical incisions may impede normal movements). Patients should also be taught how to walk and how to get into and out of bed safely and, in case other methods fail, how to fall gently (e.g., by walking close to a wall and leaning into the wall if they feel themselves falling). Patients should be told what to do if they fall (i.e., wait for assistance rather than attempt to get up). Instructions on the safe use of wheelchairs, canes, and walkers should also be provided.
Discharge instructions also provide another opportunity to remind patients about situations that may increase their risk for falls and to reinforce prevention measures.
Many patient falls occur when the patient does not have the assistance of nursing personnel—even though the patient is instructed to get up only with the assistance of nursing staff. A study of data from 2011 of 166,833 patient falls found that 85.5% of the falls were unassisted. The study also found that patients who experienced falls during a stay on a unit that did not have a fall prevention protocol in place had higher odds of falling unassisted than those who fell during a stay on a unit that had such a protocol. Additionally, compared with falls on surgical units, falls on medical units or medical-surgical units were more likely to be unassisted. (Staggs et al.)
Some hospitals have had success decreasing the incidence of falls at their facilities by adopting a regular schedule for nurses to conduct rounds of patient rooms to check on patients' needs. The concept of rounding is not new to nursing; what is new is the idea of regularly using patient rounds to focus on measures to preempt a fall by checking on a patient's needs and comfort and assessing the room for fall hazards.
A six-week nationwide study of nurse rounding every one to two hours of patients from 27 nursing units in 14 hospitals compared to control groups confirmed the effectiveness of this strategy to reduce nurse call-light use (patients' needs were addressed during rounding, so patients did not need to use the call light to request assistance) and the incidence of patient falls. The one-hour rounding group conducted hourly rounds of patients except between the hours of 10 p.m. and 6 a.m., when rounding was performed every two hours. The two-hour rounding group performed rounds every two hours during the entire 24-hour period. Although the incidence of falls was lower in the two-hour rounding group than in the control group, the finding was statistically significant only for one-hour rounding. (Meade et al.)
Scheduled rounding has led to measurable improvement in some hospitals. For example, a Rochester, New York–based health system reported that despite having a comprehensive falls management program, only after implementing hourly rounding were they able to achieve their target for falls reduction (Smith and Cropo). The system achieved hourly rounding by rotating the responsibility between nurses and care technicians, with nurses rounding during the odd hours and care technicians rounding during the even hours. Hourly rounding continues into the night shift, although patients are not awakened for an assessment. During visits to patient rooms, patients are offered toileting assistance, asked about their pain levels and need for pain medication, assessed for any need to be repositioned in bed, and assured that necessary items—tissue, telephone, television remote control, water, and call light—are within reach. Once hourly rounding was implemented housewide, the organization's falls rate dropped from 4.8 to 3.4 per 1,000 patient-days over a 14-month period. Other benefits from the program include a decrease in the incidence of pressure ulcers, less frequent use of call lights, and improved customer satisfaction.
Given that many falls occur when a patient is trying to reach the toilet, healthcare facilities have also found that toileting programs that include patient supervision by a nurse during voiding and increased frequency of patient rounds to assist with toileting may reduce falls rates (Lyons). A three-month study on patient falls at the Washington University School of Medicine (St. Louis, Missouri) concluded that half of patient falls were related to elimination needs. Nearly 50% of these falls involved patients who had been left alone to void after being helped to reach the bedside commode or bathroom (Hitcho et al.). In a study on patient falls conducted at the University of Virginia Health Systems (Charlottesville), data revealed that patients who fell on the surgical unit did so when trying to move from their bed to the bathroom. This led to the implementation of unit-specific focused interventions emphasizing frequent toileting in the surgical unit (Joint Commission Resources "Rise in Falls Rates"). Studies conducted at another large acute care facility indicated that the most effective intervention used to reduce patient falls was toileting rounds conducted every two hours, with an additional round for certain patients between 5:30 and 7:00 a.m. (Ward et al.). Risk managers should ensure that their facility's falls management program incorporates nightly toileting rounds and that staff remain with the patient or resident while he or she is in the bathroom.
Preventing Falls in Hospitals toolkit, AHRQ recommends hourly rounding as an excellent basic strategy. During rounds, AHRQ suggests checking on the "4 P's" or "5 P's." For example, the 5 P's include the following (AHRQ):
- Pain: Assess the patient's pain level. Provide pain medicine if needed.
- Personal needs: Offer help using the toilet; offer hydration, offer nutrition, empty commodes/urinals.
- Position: Help the patient get into a comfortable position or turn immobile patients to maintain skin integrity.
- Placement: Make sure patient's essential needs (call light, phone, reading material, toileting equipment, etc.) are within easy reach.
- Prevent falls: Ask patient/family to put on call light if patient needs to get out of bed.
Sitters. An alternative to regularly scheduled rounding is the use of one-to-one sitter programs (paid or volunteer). Sitters serve as an extension of the nursing staff to provide constant supervision of high-risk patients or residents. These programs, also known as continuous observation, require one-to-one monitoring to ensure that the patient has proper support during any attempts to move; such support may reduce an individual's risk of falling. This option requires the establishment of patient eligibility criteria, education, and assignment of voluntary or employed sitters; formal distinctions between the role of a sitter and that of licensed or certified care staff; and a means of addressing the program's financial costs. According to AHRQ, sitters, or more intensive supervision, may be needed for patients who have been assessed as being cognitively impaired and who are agitated or trying to wander (AHRQ). The tool Patient Sitters or Companions is available on the
While it is estimated that almost all hospitals use sitters, there is little evidence that sitter use is effective in decreasing falls and other adverse events. ECRI Institute PSO has received reports of events, such as falls, that have occurred while sitters have been in patient rooms. Some studies have found marginal value in adding sitters, but many others have identified negative or inconclusive results related to sitter use.
For example, a literature review of the efficacy of patient sitters in 12 studies conducted between 1995 and 2013 found that, although sitters were used up to 68% of the time to prevent patients from falling, only 2 of the studies reviewed demonstrated a positive effect from the use of sitters. However, the care environment in these studies was also modified, which may lessen the efficacy attributable to the sitters. Likewise, the review authors note, a decrease in sitter use did not result in an increase in patient falls, though sitter reduction often occurred when other falls prevention methods (e.g., bed and chair alarms, medication review) were implemented. (Lang)
Another study cautions against the use of sitters, explaining that "studies that involve increased observation and surveillance by nursing appear to have a more consistent positive effect on falls rates" than studies that involve nonnursing sitters. Thus, if a sitter is present, nursing should continue to provide observation and surveillance. A sitter who is part of the nursing team (i.e., nursing assistant or patient care tech) could be educated to verify that fall prevention interventions in the patient care plan are in place, including standard precautions and those tailored for the patient's specific risk factors. Thus, there appears to be lower value in a volunteer sitter (a sitter who is just observing). (Degelau et al.)
Despite the evidence against the use of sitters, some studies do show that they can reduce harmful falls. Research from data submitted by hospitals participating in a CMS-sponsored Healthcare Engagement Network falls initiative demonstrated that low "falls with harm" rates were associated with three specific sitter-program design elements: defining criteria for sitter qualifications, providing a training program for sitters, and establishing a pool of sitters. (Feil and Wallace)
Sitter programs may be expensive, especially for the limited value they seem to provide in preventing patient falls (for more information, see
Do Sitters Make a Difference?). Other fall prevention strategies may be more appropriate, such as brief but frequent contact with staff (e.g., intentional rounding). However, sitters are necessary in certain situations, such as to monitor patients with suicidal or homicidal ideation. In such cases, the facility must ensure that sitters have the appropriate training and support to effectively help the patient.
Some studies have provided evidence that low staffing levels increase the likelihood of adverse outcomes, including a greater risk of falling. For example, researchers at Barnes-Jewish Hospital (St. Louis, Missouri) have reported that falls rates are generally higher in services with higher patient-to-nurse staffing ratios (Hitcho et al.). This may mean that encouraging patients to use a call bell for assistance or installing bed-exit alarm systems will be ineffective if nurses are assigned to a large number of patients and do not respond in a timely manner to patient call lights. In these situations, staff may be rushed or distracted when interacting with patients.
While the results of this study and others are striking, facilities and managers who face chronic staffing shortages may have difficulty addressing this issue. Conversely, a study of the effects of California's mandated nurse staffing ratios has not shown a statistically significant correlation between increased staffing and a reduction in falls (Burnes Bolton et al.).
Facilities are encouraged to track staffing levels and mix (the relative percentage of registered nurses, nursing assistants, and nurse aides) when reviewing falls events or near misses to see if a correlation exists. Additionally, facilities should examine patient acuity levels in units experiencing high rates of falls; higher patient acuity levels can place more demand on staff time and may require higher staff-to-patient ratios. For more information, see the guidance article
Evaluate the Environment
Action Recommendation: Ensure that environment-of-care rounds are conducted regularly to reduce or eliminate extrinsic risks (e.g., equipment in poor repair, clutter, inadequate lighting) whenever possible; provide a mechanism for patients, visitors, and staff to report extrinsic risk factors whenever identified.
Patient rooms should be evaluated and modified to meet the needs of individual patients. For example, staff should determine each patient's stronger side and ensure that the patient exits the bed from this side. High-risk patients should be located in rooms closest to nursing stations (U.S. VA). Other environmental modifications include the use of architectural aids or other adaptations to reduce the patient's risk of falling. In bathrooms, for example, these might include elevated toilet seats, black toilet seats, chairs or benches in showers, and handrails. For a list of other interventions addressing extrinsic factors, see
Reducing Extrinsic Factor Risks.
Patients and family members, as well as staff, should be educated about and encouraged to watch for and report physical hazards (e.g., inadequate lighting, awkward intravenous lines, slippery floors) that might contribute to a fall. Once a hazard is reported, the facility must take action quickly to remove or reduce the risk.
Reduced Use of Restraints
In response to federal and state regulations and accrediting entity standards against the use of physical and chemical restraints, facilities have reduced their reliance on restraining patients as a means to prevent falls. They must balance the requirement to foster independence and autonomy in their patients against what staff and families might perceive as the need to keep them "safe."
Federal regulations regarding restraint use state that patients have "the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time." (42 CFR § 482.13[e]) These regulations provide facilities with evidence of the standard of care for not applying restraints to patients, but they are little comfort to family members who believe that their loved ones will fare better with restraints, such as bedrails. It is important to communicate to patients and families that restraint use may be hazardous to patients, leading to rapid physiologic and psychological deterioration (e.g., skin breakdown, muscle and bone loss, infection, incontinence, depression, anger) (Mion and Strumpf). In addition, restraints can drain nursing resources and can potentially cause entrapment, increasing the risk of severe injury or death if the patient tries to escape from or remove the restraint (U.S. VA).
Falls management programs should address the issue of restraint use in all pertinent policies and should provide caregivers—who often suffer from feelings of guilt and depression when required to use restraints (Joint Commission Resources "Preventing Falls")—with guidance on the proper use of restraint interventions for situations in which all other interventions have been tried and failed. Facilities are sued more frequently for improper use of restraints than for absence of restraints. Therefore, they must provide ongoing staff education that emphasizes alternatives to restraints and, when restraints are medically necessary, the proper use of restraints (Hakim).
When using restraints, staff must exercise extreme care and strictly adhere to appropriate policies and care procedures for applying restraints and monitoring restrained patients. (See the guidance article
State and federal standards for restraint use and the case law articulating these standards should be carefully reviewed on a regular basis because they continue to evolve. State laws regarding restraints require particular attention. If a state's code is more restrictive on the use of restraints, it will supersede the federal code (42 CFR § 482.13[f][ii]).
The proper selection and use of technology to reduce the risk of falls is an important component of any falls management program. As with any equipment deployed in a healthcare facility, the equipment used for falls management must be routinely and properly maintained and inspected.
Bed-exit alarms. Bed- or chair-exit alarm systems are used in the acute care arena, long-term care settings, rehabilitation units, and occasionally in home care settings. The alarm will alert staff that patients who should not leave their bed or chair unassisted are in fact doing so. Examples of bed-exit alarms include pressure-sensitive exit alarm systems (e.g., bed, floor mat), cord-activated alarms, patient-worn alarms, and bedside infrared beam detectors (ECRI Institute "Bed-Exit").
Critics of bed alarm systems state that insufficient evidence exists to recommend use of bed alarms as a strategy for reducing patient falls (Lyons) and that the use of these items can create a false sense of security among staff because the alarm cannot prevent a patient from getting out of bed or from falling. ECRI Institute has conducted evaluations of bed-exit alarms and reached the following conclusions for effective deployment of alarm systems:
- Bed alarm systems should not be used as the sole means of preventing falls.
- Pressure-sensitive alarms may not be appropriate for low-weight patients or residents who may not trip the alarm properly or for highly agitated patients or residents who may cause false alarms.
- The success of alarm systems in preventing falls depends on adequate staffing levels and timely response to alarms. Training on the use and maintenance of these systems is also required.
Bedrails and high-low beds. To reduce the risk of patient injury from falling out of bed, facilities should avoid the use of full bedrails and use high-low beds whenever possible. Full bedrails will not prevent a determined patient from getting out of bed. Indeed, the use of full bedrails increases the likelihood of falls and entrapment for patients or residents trying to climb over them (Hospital Bed Safety Workgroup).
Facilities should not have standing orders for bedrail use; all use of bedrails should be based on individualized assessment. When considering the use of bedrails for an individual, an interdisciplinary team in consultation with the patient and his or her family must weigh the risks of using bedrails against not using them. If it has been determined that bedrails are required and can benefit the individual (e.g., help the patient turn or change position within the bed, provide support for exiting the bed), facilities must ensure that the patient or resident is monitored closely. (Hospital Bed Safety Workgroup) Partial bedrails can also be considered. The risk of entrapment is reduced because the patient does not need to climb over the rails or footboards to get out of bed.
CMS no longer considers certain uses of bedrails to prevent a patient from falling out of bed to be restraint use. CMS states that the use of the bedrail is not to be considered a restraint if it is based on the individual's needs; if the purpose of the bedrail is to prevent the individual from falling out of bed or to aid in positioning while the patient is in the bed or transferring out of the bed; and if the individual demonstrates that the bedrail does not impede his or her ability to leave the bed. Still, CMS recognizes that bedrail use can pose risks to the patient (CMS "Medicare and Medicaid Programs"). For example, if a patient cannot move the bedrails without assistance, the bedrails should be considered a form of restraint.
High-low beds should be used whenever possible and should be left in their lowest position to allow ambulatory patients freedom of movement and to reduce the risk of severe injury from falls from bed. Housekeeping concerns may arise with the use of lower hospital beds because the beds must be raised to allow staff to clean the floor and then lowered again. Falls management policies should specify that beds must be kept in the low position and returned to this position if raised for cleaning. Housekeeping staff must understand the importance of this policy from a patient safety perspective.
Nurse call systems. The Joint Commission notes that communication failures and unavailable or delayed medical care are significant risk factors that can contribute to falls, especially in patients with limited mobility. The organization has identified improvement and standardization of nurse call systems as an important strategy for overcoming fall risks (Joint Commission "Fatal Falls"). For nurse call systems to be effective, patients at risk of falling must be instructed to avoid ambulating or getting out of bed without assistance. By enforcing regular nurse rounding of patient rooms so that nurses can check on patients' needs, facilities have been able to reduce the incidence of falls and the need for nurse call requests (Meade et al.).
Ambulation and transfer aids. Interventions such as assistive devices and transfer aids are commonly used to reduce a patient's falls risk. Assistive devices include canes, walkers, gait belts, and wheelchairs. Transfer aids include grab bars, transfer poles, and overhead trapezes. Of course, before compensatory measures such as assistive devices are considered, every effort should be made to identify the reason the assistive device is needed. For example, an evaluation of the individual's feet and footwear might indicate that a change in footwear could eliminate the need for the assistive device.
For these devices to be an effective component of the falls intervention program, proper assignment and fitting of equipment is essential, and staff, patients, and families must be educated on how to safely use and maintain this equipment. Without proper instruction and attention to the safe use of these aids, they can actually contribute to patient falls.
Hip protectors. Because one of the Joint Commission's patient safety goals is to reduce the harm caused by patient falls, and because facilities need to balance patient protection and patient independence, falls teams might consider implementing the use of hip protectors. Hip protectors are padded undergarments designed to prevent fractures of the trochanter (U.S. VA; Joint Commission "2015 National Patient Safety Goals"). Studies of the effectiveness of hip protectors, however, have been inconclusive. Some studies of patients in long-term care facilities in Great Britain and Germany provide evidence that wearing hip protectors results in a lower risk of fracture in long-term care patients (Vu et al.; Feder et al.; Meyer et al.). A recent review of 14 hip protector trials found no evidence that the devices significantly reduce the incidence of hip or pelvic fractures related to patient falls, especially in the home care setting. Long-term compliance among most patients was poor, making it more difficult to assess whether the devices themselves were helpful in preventing adverse outcomes. (Parker et al.) A 2007 study of more than 1,000 residents in 37 nursing homes who wore hip protectors on one side found no difference in hip fractures between protected and unprotected hips, even among residents with greater than 80% compliance (Kiel et al.).
Critics of hip protectors cite lack of patient compliance due to toileting issues, skin irritations, and general discomfort resulting from the extra padding, as well as facility concerns with the cost and sanitation issues associated with these devices (U.S. VA).
Home Care Interventions
A healthcare system has more exposure to liability for falls that occur in the hospital and long-term care setting than in a patient's home because it bears the responsibility for providing a safe environment in its own facilities. However, falls in the home can also result in claims and liability for healthcare systems that provide home care services.
One study found that 14% of patients fall in the first month after hospital discharge (NCOA). To help mitigate the risk of patient falls in the home, the Joint Commission has included reducing the risk of harm resulting from falls in its 2015 patient safety goals for its accredited home care programs. Home health agencies should approach falls management programs in a manner similar to those of other healthcare facilities, including conducting reactive analyses, because data collection and analysis provides valuable information when developing population-specific risk assessment tools. Another study, this one conducted by a home healthcare agency, found that the agency's patients most at risk for falls had cardiovascular and neurologic comorbidities, were taking medications associated with falls, and had fallen more than once within the past three months (Lewis et al.).
An assessment of home safety risks should be performed by home care professionals during the initial visit and periodically thereafter. Modification of the home environment should be encouraged when necessary. CDC has published a home falls management checklist for older adults addressing hazards such as clutter on the floor, electrical cords, insufficient lighting, slippery surfaces, and the absence of grab bars.
Resource List for information on accessing the checklist.) ECRI Institute has also developed a tool for assessing hazardous conditions in the home, see Home Safety Assessment for this tool.
Additionally, the home care provider should provide ongoing safety education in falls management for the patient and family. This education should be conducted and documented by a nurse.
Respond to Falls
Action Recommendation: Educate all staff on the appropriate way to respond to falls, including injury assessment, reassessment of the patient's risk for falling, and communication of the fall and subsequent reassessment results to family, staff, and physicians.
Action Recommendation: Communicate to staff clear and consistent policies for documenting and reporting falls, and conduct reactive analyses of the incidents to identify strategies to improve the falls management program.
Action Recommendation: Incorporate routine inspection and preventive maintenance of all falls management equipment in the healthcare facility's equipment maintenance program.
Even the most effective falls management program will not eliminate all patient falls. Thus, the falls management policy should include information on communication with patients and families when a patient falls. Separately, the hospital's disclosure policy will guide staff on how to communicate with patients and families when a significant injury—such as a hip fracture—occurs as a result of the fall. Knowing how to convey compassion without assigning blame when a fall occurs can relieve awkwardness for the staff and possibly decrease the patient's or family's inclination to sue. Facilities have had more success defending falls claims when the organization follows its policies and procedures, provides appropriate documentation, and shows compassion (Hakim). Bill write-offs may also be considered on a case-by-case basis—in accordance with fraud and abuse laws and regulations—if additional testing or treatment is required as a result of the fall.
Postfall Patient Reassessment
As soon as a patient who has fallen is discovered, an assessment must be made to determine the extent of any injuries sustained. Policies and protocols should be developed and implemented that guide caregivers and nonclinical staff on the appropriate way to respond when they discover a patient has taken a fall. The policy should specify that any staff member who finds the patient should remain with and verbally reassure the patient and call for help.
Postfall reassessment and monitoring of the patient may continue for several days or weeks. Reassessment may include a review of behavior or functional change (e.g., in gait, consciousness, neurologic function, skin integrity, appetite, or vital signs) to determine possible injury. A wide range of contributing factors should be reviewed, including medications the patient is taking and footwear he or she uses. Interviewing roommates or staff is also advised, as is interviewing the patient. A physical therapist may need to assess the patient to determine whether other physiologic factors may have contributed to the fall.
Licensed practitioners should review, determine, and communicate pertinent findings to caregivers to explain why the fall may have occurred. Caregivers should be made aware of new information from the analysis of the patient's fall as it becomes available. The risk manager should also be made aware of any findings from the reassessment. An interdisciplinary team should identify likely contributing intrinsic and extrinsic factors and adjust the plan of care to meet the individual's specific needs based on his or her current status. All information should be documented (Miceli), and staff should be made aware of the patient's falls risk status.
Communication with the patient's family must also provide objective and factual information about the event, its impact on the patient, and any treatment that may be required. The family should be assured that it will be kept informed of any in-depth analysis of the event that is undertaken to identify causative factors and prevent recurrence. Consistent with the organization's policy on disclosure, the individual who speaks to the family should document that the discussion took place.
Following the postfall reassessment and application of interventions to protect the patient, the staff involved in managing the patient must complete an event report of the incident. Procedures should be established for timely submission of falls event reports and actions to investigate and follow up on falls. Typically, the individual who witnesses or discovers the fall should report the falls event. Nursing departments are characteristically the most common source of falls event reports, but all employees must know how and be required to report falls, and professional staff, nonclinical staff, volunteers, visitors, and patients should be encouraged to report falls.
Knowing what factors are contributing to the occurrence of falls allows for better focus on corrective measures to prevent future falls. The organization should also encourage individuals to report incidents or near misses so that preventive measures can be put in place before a similar incident leads to an actual fall or injury.
Compliance with falls reporting will be more likely to occur if the facility promotes a culture of safety and views reports of adverse events as opportunities to improve systems rather than blame individuals when an adverse event does occur. (Further guidance is available in the guidance article Event Reporting and Response.)
The falls team should develop and communicate to all staff clear and consistent guidelines for documenting and reporting falls (Hake). Otherwise, there is the possibility that staff could report events inconsistently.
Falls event reports should include documentation of the following information (U.S. VA; AHRQ):
- Date/time of fall
- Days since admission
- Patient's description of the fall (if possible), including what the patient was trying to accomplish at the time of the fall and where the patient was at the time of the fall
- Whether the fall was witnessed, making clear distinctions between what was seen or heard and the patient's account
- Family/guardian and provider notification
- Whether this was the first fall of this admission or a repeat fall
- Patient vital signs (including temperature, pulse, respiration, and blood pressure—orthostatic, lying, sitting, and standing)
- A list of current medications and whether the medications were given, including whether any were given twice
- Patient assessment, including the following:
- Presence of injury and reassessment for delayed injury identification
- Type of injury
- Potential factors that may have contributed to the fall
- Comorbid conditions (e.g., dementia)
- Intrinsic fall risk factors
- Extrinsic fall risk factors
Outcomes of investigations recorded (e.g., x-rays)
- Environmental factors, including the following:
- Whether the bed was in a high or low position
- Whether bedrails were used
- Whether the bed wheels were locked
- Whether the wheelchair was locked
- Condition of floor (e.g., wet, dry, talcum powder)
- Whether the hospital had approved lighting
- Whether the patient was wearing appropriate footwear
- Whether a walking aid was used or in reach
- Whether the call light was in reach
- Whether the bedside table was in reach
- Whether the area was clear of clutter and other items
- If the fall took place in a toilet environment, also document whether the toilet was too low, if there were safety rails, or if there were slip hazards
- If a treatment plan was being followed, and if not, why it was not being followed
- Whether the falls team and other nurses on the unit were notified
Staff must understand the need to provide factual and objective information and avoid conjecture and other subjective remarks about the fall. Some jurisdictions refuse to protect event reports from discovery during the litigation process; extraneous information about a fall or opinions could be damaging to the defendant in a lawsuit.
Monitoring a Program's Effectiveness
Monitoring the organization's falls management program will help identify a falls program's strengths and weaknesses. The facility must begin with a baseline assessment and develop falls rate targets using the facility's data on past falls. Factors to incorporate in the baseline assessment should include unit and patient population and whether a fall was an anticipated physiologic fall, an unanticipated physiologic fall, or an accidental fall. Facilities may also want to evaluate the time of the fall, environmental (extrinsic) and patient-specific (intrinsic) risk factors, implemented interventions, patient activity at the time of the fall, whether the patient has fallen in the past, and the severity of any injuries sustained (U.S. VA).
Retrospective chart reviews may be used as a tool for measuring the efficacy of risk assessments and interventions. When conducting these reviews, facilities should include reports of individuals who fell and a random sample consisting of an equal number of patients who did not fall. When identifying trends or evaluating the success of interventions, facilities should compare their falls and injury severity rates from one time period to another.
The assessment should also include any equipment or interventions in use during the incident (Joint Commission Resources "Root Causes"). Facilities may also want to use the Self-Assessment Questionnaire
Falls to evaluate their falls management programs.
Address Employee and Visitor Falls
Action Recommendation: Ensure that falls policies address the prevention of and response to visitor and employee falls, including the treatment of employee falls through the facility's employee health program and visitor falls through the emergency department.
Despite the best precautions, visitor and worker falls will occasionally occur, and facilities should ensure that their managers are educated about appropriate treatment for and response to employee and visitor falls.
When an employee falls, healthcare facilities must respond by treating the worker, identifying the hazard, and taking steps to prevent similar falls. Healthcare organizations should develop and strictly follow policies and procedures with respect to treatment of employee injuries sustained in falls. One large insurance company recommends that its insured clients not treat injured employees in the emergency department (ED) but refer the employees to a separate employee health clinic to avoid liability exposure for malpractice as well as workers' compensation (Hakim).
By better preserving the employee/employer relationship, treatment in the employee health clinic will limit the facility's potential liability compared with treatment in the ED. For more information about treatment of injured employees, see the guidance article
The organization must also ensure compliance with federal and state regulations for worker safety, such as Occupational Safety and Health Administration requirements for recording all significant work-related illnesses and injuries.
In the event of a fall by a visitor, security, environmental services, and possibly medical staff should be notified immediately to enable them to respond to the event according to the facility's falls protocols and procedures. The facility should identify a mechanism for responding to visitor falls and providing aid and medical treatment. For example, some facilities may consider assigning their rapid response teams the responsibility for responding to such falls. Staff should be helpful and courteous, without accepting or assigning any blame or responsibility for the fall. Visitor falls that result in injury should be treated immediately. The facility's ED may provide medical treatment or examination following a visitor's fall. Bill write-offs for medical treatment may be considered in accordance with federal regulations.
All incidents of visitor falls—regardless of whether any injury occurred—should be reported to the risk manager as part of the organization's adverse event reporting system.
When a visitor falls, the facility must ascertain exactly what happened and why it happened. Investigators should not stop at quick and easy explanations—for example, attributing the fall to the type of shoe that the person was wearing, to an employee turning a corner and inadvertently knocking over a visitor, or simply to weather conditions.
Such solutions should instead raise another round of questions: How can the floor be made safe for this type of shoe? Why was the employee hurrying? Can the facility respond more diligently to changes in the weather? How can the premises be made safer under adverse weather conditions? Once the correct questions are asked and answered, proper corrective actions will become more obvious. This process is invaluable in fashioning corrective actions, and it may be invaluable in defending a subsequent claim.
Falls teams should ensure that personnel are conducting environment-of-care rounds to recognize, evaluate, and eliminate environmental hazards, or warn about hazards that are impractical or infeasible to control.
Predictability and preventability will likely be important factors if a falls case goes to litigation. For example, the South Carolina Supreme Court upheld a ruling that a hospital was negligent for failing to remove sweet gum trees from its parking lot after a construction company warned that debris from the trees would cause problems. A visitor filed suit against the hospital after suffering injuries from a fall in the hospital's parking lot allegedly caused by an accumulation of the ball-like fruit of the sweet gum tree. The failure to take reasonable remedial action in response to a reported hazard may help support a finding of negligence. (Henderson v. St. Francis Community Hospital)
Visitor falls that result in injury should be reported immediately to the risk manager; if no injury occurred, the fall should be reported through the hospital's adverse event reporting system.
Effective Interventions for Hospital Falls Management
In a unique regional collaboration, hospitals from the Philadelphia area worked together to identify strategies to prevent patients from falling. The 60-plus falls management strategies identified as effective by the participating hospitals include the following:
- Develop and implement a list of the medications likely to increase a patient's risk of falling for nurses' reference when they assess a patient's falls risk.
- Enlist the pharmacy department's assistance to place stickers on medications indicating high falls risk.
- Retrospectively track falls related to medications to identify high-risk medications, and add them to the high-falls-risk medication list.
- Utilize whiteboards at the nurse station to identify patients at high risk of falling.
- Clip a color-coded visual identifier for high falls risk to wheelchairs and stretchers during transport of patients who are at high risk for falls.
- Develop a laminated pocket guide with the organization's falls management policy and procedures for physicians and nurses.
- Question family members about patient behaviors related to time of day (e.g., expected behaviors at morning and evening hours).
- Implement hourly rounds to assess or to address patients' personal needs (e.g., toileting).
- Implement a patient sitter program for patients who are at high risk of falling and who do not adhere to falls management interventions.
- Educate all staff regarding the use of visual identifiers for patients at high risk for falls.
- Implement an education campaign on the organization's falls management program that includes new, existing, and per diem staff.
- Provide follow-up education for staff who do not adhere to falls management measures.
- Incorporate simulation in staff education (e.g., rub petroleum jelly on eyeglasses to simulate a patient's visual impairment and risk of falling).
Sources: Partnership for Patient Care. Failure mode and effects analysis: falls prevention.
Plymouth Meeting (PA): Partnership for Patient Care; 2007; Pelczarski K, Wallace C.
Hospitals collaborate to prevent falls [online].
Patient Saf Qual
Healthc 2008 Nov-Dec [cited 2015 Oct 26].
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Reducing Extrinsic Factor Risks
The following interventions can be implemented to reduce extrinsic risk factors:
- Use floor-level nightlights (avoid nightlights that merely create shadows and glare).
- Keep beds in their lowest position.
- Keep toilets in their highest position.
- Avoid using full-length bedrails (patients may attempt to climb over them).
- Keep floors uncluttered, and remove low objects that could cause a patient to trip.
- Have patients wear slip-proof socks or well-fitting, appropriate shoes.
- Ensure that patient clothing will not cause tripping (e.g., avoid use of long gowns).
- Cordon off wet floors and construction areas.
- Make caution signs understandable to all visitors.
- Leave dry areas around wet floors when possible.
- Do not overwax floors.
- Minimize glare on floors; consider using no-glare floor wax that is available for hospitals.
- Consider carpeting higher-risk patient areas (e.g., geriatric units).
- Ensure that carpets are properly installed and maintained to ensure that they do not have ripples or bumps.
- Use color contrasts to clearly identify steps and grade changes.
- Choose flooring patterns and colors that are calming; avoid color combinations—such as blues and greens—that older adults have difficulty differentiating.
- Provide skidproofing materials in showers, tubs, bathroom floors, and stairs.
- Consider using surface applications to increase the coefficient of friction of marble or granite floors in public areas that are likely to become wet and slippery as a result of inclement weather (e.g., foyers).
- Avoid furnishings that might slip when leaned on for support (e.g., wheeled tables), or ensure that wheels
- Perform regular preventive maintenance on mobility aids (e.g., canes, walkers, wheelchairs, lifts).
- Avoid furniture with sharp corners.
- Install grab bars and wall rails in patient rooms, bathrooms, and hallways.
- Advise home care patients not to use throw rugs.
- Minimize distracting noises.
- Time the mopping and/or vacuuming of high-volume traffic areas appropriately.
- Maintain a quick response time for cleaning up spills and other hazards.
- Take appropriate precautions with outdoor walkways to guard against icy conditions, construction hazards, and uneven surfaces.
- Maintain appropriate staffing levels on par with patient acuity levels.
- Use restraints in the least restrictive manner possible and only when all other interventions have proved to be insufficient; provide frequent monitoring of patients who are in restraints.
Source: U.S. Department of Veterans Affairs.
Interventions. In: National Center for Patient Safety. Falls toolkit [online]. 2004 May [cited 2008 Dec 2].
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