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Developing an Evidence-based Interdisciplinary Fall Reduction Program
Jennifer Smith
NUR 598
June 15, 2012
Naja McKenzie
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Abstract
The purpose of this study is support the hospital’s commitment to providing a safe environment for
their patients by preventing falls and reducing fall-related serious injury. The project consists of working
with an interdisciplinary team to develop, implement, and evaluate an evidence-based fall risk
assessment tool to identify high-risk patients. A fall risk in the hospital setting may increase the length
of stay, cost of hospitalization, and utilization of resources. Patients that fall during hospitalization have
psychological and physical effects from a fall and have an increased risk of morbidity and mortality
(Fonda, Cook, Sandler, Bailey, 2006). A fall risk reduction program that is interdisciplinary will be more
effective at reducing the risk of falls.
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Problem Identification
Emerging reimbursement methods such as pay for performance penalizes for negative consequences
such as fall-related injuries during hospitalization. Falls that occur in the hospital are a risk management
problem and decrease the patient’s satisfaction and perception of the quality of care. The hospital’s
current policy and procedure for falls does not meet national standards; the pediatric population is not
assessed for their risk for falls. The organization has had an increase in patient falls per patient days and
falls that result in moderate to severe injury in 2011. To meet national accreditation standards the
organization must review their policy and procedures, develop a strategy to reduce the number of falls
and falls with injury, and continually monitor its effectiveness.
Solution Description
The proposed solution is the development of a fall-risk reduction program that uses evidence-based
assessment tools for adult and pediatric patients and interdisciplinary feedback from pharmacy, physical
therapy, physicians, and nurses. The Morse Fall Scale will be used to assess adult inpatients and the
Humpty Dumpty Scale will be used for pediatric inpatients. A screening process will be used to identify
outpatients entering the facility for fall risk and interventions will be developed for those identified atrisk for falls. Care plans will be individualized with interventions based on patients fall risk category with
appropriate referrals to interdisciplinary team members. Universal fall precautions will be implemented
for all patients and interventions will increase for those identified as moderate, high-risk, and high-risk
with mental impairment.
The proposed solution is consistent with evidence-based practice; literature review indicates that fall
reduction programs are more effective when they involve interdisciplinary teams and consider
multifactorial reasons for patient falls. The project is a feasible low cost solution to increase
surveillance, optimize the environment, and improve the management of patients at-risk for falls. The
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program consists of the development of a fall reduction policy, revision of fall-assessment tools,
education of staff, and evaluation of outcomes.
The fall reduction program is consistent with the organization’s mission statement, “to provide high
quality, comprehensive, safe and compassionate health care services” (Samaritan, 2012). The
organization’s vision is to be recognized as the preferred provider in the community. The nursing
division’s mission supports the organization’s vision to provide high quality, compassionate care
supporting the patient’s mind, body, and spirit through human to human caring. Nurse care is patientcentered based on Jean Watson’s Caring Theory. The nursing staff collaborates with other health team
members to meet the psychosocial, physical, and spiritual needs of the patient and their families. The
nursing division is committed to providing staff with continued competency training and educational
programs.
Developing an Evidence-based Interdisciplinary Fall Reduction Program
Literature review of best practices, fall risk assessment tools, and the importance of an
interdisciplinary approach to reducing falls will be conducted and summarized in an annotated
bibliography. The current fall reduction policy will be compared with best practices, National Database
of Nursing Quality Indicators (NDNQI), and national accreditation standards. Findings will be reviewed
with the Director of Nursing (DON) for input and approval of the project.
Involving Formal and Informal Leaders
The Director of Pharmacy will be involved to explore the possibility of adding a pharmacological
review of medications of high-risk patients. The Director of Quality will be consulted to assist with
developing a multidisciplinary fall team that will periodically evaluate the effectiveness of the fall
reduction program. The Director of Physical Therapy will be asked for input on the development of the
policy and the physical therapist’s role in fall reduction. A meeting will be held with Information
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Services to determine the length of time and process to make changes to the fall assessment tool in the
electronic medical record. Best practices will be reviewed with nurse managers of different units and
the Nurse Practice Council; feedback will be received on fall reduction strategies that will work for our
organization.
Policy Development
A draft policy will be developed that incorporates evidence-based practice and feedback from other
disciplines and reviewed by the DON for suggestions prior to submitting to the Policy and Procedure
Committee for approval. The draft policy will include updated nursing care plans and patient/family
education materials. The draft policy will be reviewed at the nurse leadership meeting for nurse
managers to have a last minute opportunity to provide feedback prior to approval. Once the policy is
approved changes will be made to the documentation system.
Education Program
Following approval of the policy, an educational program will be developed to include: learning
objectives, content outline, and Power Point that will be loaded on the computer education module net
learning with a post-test to determine competency. The educational program will be reviewed by the
Nurse Educators for final approval prior to being placed on net learning. A post-fall analysis will be
developed to assist with identifying areas for improvement and assist with evaluating the reason for the
fall. Materials will be ordered by the nurse managers such as: yellow star door magnets, gait belts, and
bed/chair alarms. Employees will participate in developing a patient education video that will be loaded
on the television educational channel.
The proposed solution is a feasible cost-effective and necessary to reduce inpatient falls and meet
national accreditation standards. The solution is consistent with the hospital’s mission, vision, and
values of providing high quality care. Monitoring the implementation plan is important to ensure
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activities are executed as planned. The DON will assist with ensuring that the implementation phase is
carried out as scheduled.
Research Support
Literature review will consist of: 5 peer reviewed research articles on fall risk assessment tools and
interventions, 15 peer reviewed research articles on fall reduction programs and best practices, and 5
peer reviewed research articles on the importance of interdisciplinary feedback in the development of
fall reduction programs. A summary of 6 of six of these research studies are as included in this paper.
Multidisciplinary Approach to Fall Reduction
A three year research study performed 2001-2003 at General Medical Center in Melbourne, Australia
indicates incorporating a fall risk program into all levels of the organization. This method is important to
the success and sustainability of a fall prevention program. All patients admitted during the time frame
were included in the study. A multi-strategy approach including revising the definition of fall, choosing a
fall risk assessment tool, developing interventions based on assessment score, implementing practice
changes, environmental and equipment changes, and staff education. The result of the study after two
years showed a 19% reduction in falls and a 77% reduction in falls that result in serious injury. The study
also revealed an increase in staff compliance with the fall risk assessment tool (Fonda et al, 2006).
Pharmacological Review of Medications
A research study performed in 2005 at Mercy Health Center (MHC) in Oklahoma City supports the
importance of pharmacological review to identify patients at high-risk for falling based on medication
assessment. Certain medication classifications have adverse effects that cause dizziness, orthostasis,
and sedation. Developing a fall prevention program that incorporated a medication review by a clinical
pharmacist resulted in a 30% reduction in falls, 48% reduction in injuries from falls and a savings of
$217,000 within two years of implementation.
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MHC developed a Medication Fall Risk Score (MFRS) using Beers criteria and Lexi-Comp’s Drug
Information Handbook, and the American Hospital Formulary Service to categorize patients as high,
medium, or low-risk for falling based on a medication profile. The medication profile was reviewed by
clinical pharmacists and their recommendations were communicated to the prescribing physician in the
progress notes and notification sent to the nurses to reinforce the high-risk fall care plan. Patients
identified as high-risk for falls without cognitive impairment received medication adverse effects
counseling from the pharmacist. JCAHO require patients to be assessed for their risk of falling including
review of medication regimen and organizations develop strategies to reduce risks (Beasley &
Patatanian, 2009).
A retrospective case-crossover design study at Fukuoka Medical center a 600-bed acute care hospital
in Japan indicates a strong correlation between certain medication classifications and falls. The study
further indicated that newly initiating angiotensin II receptor antagonists, antiparkinsonian agents,
antianxiety medications, and hypnotic agents increased the risk of falls. A total of 349 inpatient falls
were reviewed for a 30 month timeframe from March, 2003-August, 2005; data collected from incident
reports and medical records to assess an association between medication use and risk of falling. The
case period was defined as the 3-day period just before the fall. To estimate the odd ratio with respect
to medications they used conditional logistic regression analysis. Medications were divided into nine
groups to evaluate an association between medication classes and falls. Falls related to medication use
were computed using conditional logistic regression analysis and determined to have an odd ratio of
95%. The study concluded that medical professionals should be aware of the possibility that starting
new medications may trigger the onset of falls and implement preventative strategies (Shuto, Imakyure,
Matsumoto, Egawa, Jiang, Hirakawa, Kataoka, Yanagawa, 2010).
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Adult Fall Risk Assessment Tools
A descriptive and cross sectional study compared the sensitivity, specificity, and feasibility of four fall
risk assessment instruments: (1) Hendricks II Fall Risk Model, (2) New York Presbyterian Fall and Injury
Risk Assessment, (3) Maine Medical Center, (4) Morse Fall Scale. Data was collected from May-June
(2006) on 17 units and 1,546 patients were reviewed with results indicating that the Morse Fall Scale
had the highest accuracy rate of 100% (Chapman, Bachand, & Hyrkas, 2011).
Pediatric Fall Assessment Tools
A case-control study at a pediatric teaching facility was conducted from 2005-2006 to assess the
relationship between the Humpty Dumpty Fall Scale (HDFS) and the actual event of a fall. The HDFS
assesses pediatric inpatients for risk of falls. The study was developed through literature review and
intense discussion among nurses with extensive pediatric and adolescent experience. Chart reviews of
308 patients were done: 153 were children who fell during hospitalization and 153 were children that
did not fall. The cases and controls were matched for demographics of age, gender, diagnosis, and unit
location. Data was collected from medical, surgical, respiratory, neurology, oncology, and pediatric
intensive care. A group of advanced practice nurse practitioners, clinical nurse specialists, directors, and
staff nurses conducted the review and completed the HDFS scoring. The reliability in scoring the HDFS
was calculated at 70% (Hill-Rodriguez, Messmer, Williams, Zeller, Williams, Wood, & Henry, 2008).
Hill-Rodriguez et al. (2008) reported the HDFS to have a sensitivity of 0.85 and specificity of 0.24 with
a positive prediction power of 0.63. The number of patients correctly classified was 59.3%. The
significant sample size suggests that the HDFS may be the best fall scale available to assess the pediatric
population. The odds of high-risk patients falling were twice that of a low-risk patient. Pediatric risk
assessment of falls could target children at risk for falls and allow staff to implement appropriate
interventions.
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Evidence-Based Practice
A pilot project developed by the interdisciplinary falls team at New York Queens, a 500-bed culturally
diverse community academic medical center showed a significant reduction in fall rates. The concept of
the fall reduction program was that fall reduction was responsibility of all employees; each team
member having different roles and responsibilities. Team building was a priority in reducing the number
of falls and included in the educational program. All hospital employees attended a three hour
education program taught by a doctorally prepared expert in gerontologic nursing. Each unit had a
registered nurse “champion” that provided on-going coaching and mentoring to maintain the
sustainability of the program. A reduction in falls was noticed immediately after the education of staff
and within six months the fall rate decreased from 11.48 per 1,000 patient days to 3.17 (Wexler, O’Neil,
D’Amico, Foster, Cataldo, Brody, Zheng-Bo, 2011).
The project was eventually called the “Ruby Red Slipper Program” because patients that were
identified as high-risk for falls were given red non-skid socks. Staff input during the development of the
program indicated this would be better than signage. Other interventions included improved
communication between shifts, ticket-to-ride, and completing a post-fall analysis immediately after the
fall. Monthly data was disseminated on each unit for staff to track improvements.
Implementation Plan
Change Theory
Lewin’s Change Theory was chosen to assist with the development of the implementation plan. Kurt
Lewin developed a three-step model to assist with organizational change which includes the following
steps: unfreezing, movement, and refreezing (Kristsonis, 2004). The first step of the process, unfreezing
consists of analyzing the current fall policy and making the employees realize that change needs to occur
to align our fall policy with best practices. The second step is movement, which involves persuading
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employees to agree that the current policy is not meeting best practice standards and involving them in
the process by brainstorming and providing feedback during the development of the policy. The third
step, refreezing is necessary to sustain changes so the employees do not revert back to old behaviors
and practices. This step will be particularly important for the project to maintain the fall reduction
program and monitor its effectiveness.
Budget
The majority of this project will be completed by the nursing project manager on a volunteer basis.
Indirect costs include meeting with the DON, Director of Quality, Director of Pharmacy, Director of
Physical Therapy, Information Systems, and Nursing Educators. The costs associated with these
meetings are approximately $250 dollars. The time spent on clinical informatics making necessary
documentation changes in the computer system are $320. A time frame will be allotted to existing
committee meetings for the Nurse Practice Council, Nursing Leadership, and Policy & Procedure
Committees. Direct costs for this program include printing educational materials for patient/family
education which is a JCAHO requirement. Employee’s times associated with the development of a
patient/family education video that will be placed on the patient education channel are estimated to be
$700. Materials will have to be purchased such as: yellow star magnets, yellow arm bands, gait belts for
each room, bed/chair alarms for each room. The initial cost for the materials is estimated to be $7546
for the entire hospital. The bed/chair alarms and gait belts will have to be periodically replaced. Each
unit should have enough to have one of each item per room. These items will have to become part of
the nursing unit’s annual budget. There is a possibility that pharmacy will need another clinical
pharmacist depending on the volume of patients classified as high-risk requiring a medication review.
The cost of an additional clinical pharmacist is approximately $117,000 annually.
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Evaluation Plan
The number of falls will be analyzed for three months after the implementation of a new policy with a
goal of reducing the number of falls by 25%. At least 50 charts will be audited to analyze correct use of
the fall-risk assessment tool, initiation of care plan, and documentation of education with the goal of
95% accuracy.
The problem with assessing the effectiveness of a fall program is that the definition of a fall varies
depending on the organization (Rutledge, Donaldson, & Pravikoff,, 1998). The Joint Commission on
Accreditation (JCAHO) permits an organization to define what they consider a fall. The newly developed
policy will use the National Database of Nursing Quality Indicators (NDNQI) definition of a fall: “An
unplanned descent to the floor, either with or without injury to patient/resident/client” (ANCC, 2008).
The policy will also standardize the level of injury to the NDNQI definitions: (1) none (patient did not
sustain and injury from the fall, (2) minor injury (indicates those injuries requiring a simple intervention,
(3) moderate (requires sutures or splints, (4) major (requires surgery, casting, and further exam), (5)
death (resulting from injuries sustained from the fall). Having standardized reporting will assist with
determining the successfulness of the fall reduction program.
Outcome Measures
The effectiveness of the fall reduction program data will be measured by monitoring data on fall
incidence, severity of injury, percentage of repeat fallers, and number of days between major injuries.
Fall rates will be analyzed for overall facility using the following formula (number of patient falls/number
of patient bed days) x 1000. This method adjusts for fluctuation in census and is the recommended
method by the American Nurses Association (ANA). The disadvantage to this method is that it calculates
all falls including the number of repeat fallers. The number of repeat falls will be measured to
determine what percent of the falls are second, third, fourth, or more falls. The injury rate will be
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measured by using the following formula (number of injuries/number of falls) x 100. This method is
recommended by the Department of Veteran Affairs, calculating the injury rate per 100 falls produces a
meaningful rate. The number of days between major injuries will indicate the program’s overall success
if the length of time between major injuries increases (Quigley, Neily, Watson, Wright, & Strobel, 2007).
Data will be further analyzed by unit to determine opportunities for improvement.
The effectiveness of the education program will be monitored by staff completing a post-test. At
least 50 charts will be analyzed after implementation to assess for the correct use of the Morse Fall
Scale Risk Assessment, appropriate care plans completed, documentation of patient/family education,
and use of appropriate interventions such as wrist band/non-skid socks.
Evaluation of Data Collection
Data will be analyzed by reviewing incident reports and the post-fall analysis. The current
computerized incident report system makes it difficult to extract meaningful data. A post-fall analysis
was developed to assist with data collection and is to be performed during a post-fall huddle on the unit
and handed in with the incident report. The post-fall analysis is a modified version of The Texas Medical
Center Council of Nurse Executives Collaborative Patient Fall Prevention Protocol (2009) (see Appendix A
Post Fall Analysis). The tool was modified using the Situation, Background, Assessment,
Recommendation (SBAR) format. The staff is currently educated on the SBAR format and uses it to
assist with communicating with health care providers.
According to Throckmorton et al (2009), the concept of post-fall huddles was developed by James
Haley for the Veteran’ Administration Hospital with a grant from the Robert Wood Johnson Foundation
and has been evaluated to be an effective method to assist staff to determine the root cause of the fall
while the information is still fresh in their minds. A data spreadsheet will be developed to monitor data
from the post-fall analysis such as: age, primary diagnosis, pre-fall risk score, activity at the time of fall,
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shift patient fell, day of the week, location of the fall, and length of hospital stay (see Appendix B). This
information will also assist with submitting the fall data to the NDNQI database which requires a
demographic profile (age, gender, diagnosis). The data gathered from the post-fall analysis will be used
to develop a visual presentation of fall data and used to trend over time. This data will allow staff to
understand how the data correlates to the fall reduction program and patient outcomes. Fall data will
be analyzed on a quarterly basis by an Interdisciplinary Fall Team consisting of quality, pharmacy, nurse
leaders, physical therapy, Patient Care Coordinators (PCC), and each inpatient unit will have a
designated fall champion. The fall data will be analyzed for trends and opportunities for improvement.
Nursing units with a higher than average fall rate will be reviewed for contributing factors and a plan of
correction developed by the department manager.
Resources Needed for Evaluation
The post-fall huddle will require the staff’s time to discuss the potential for the fall and will require
the registered nurse additional time to complete the form. An incident report and documentation in the
medical record are already required. Some units are already completing a post-fall analysis for their
nurse managers, but the form is not organizational specific and there is inconsistent use. Nurse
Managers are presently required to review the incident reports and respond in the computerized
incident report system Med-QM. The information provided on the post-fall analysis will decrease the
amount of time the nurse manager must search through the medical record for necessary information
to respond to the incident report. The nurse manager on each unit will turn in a completed data
spreadsheet to the PCC group on a monthly basis. The PCC group already meets bi-weekly and the fall
data analysis will be added to their agenda. The educational program and post-test will be loaded onto
the hospital’s computerized education module. The resources required to monitor the effectiveness of
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the project are minimal and feasible to implement. Supplying resources to plan, implement, monitor,
and evaluate the fall reduction program will align the fall reduction program with national standards.
Decision-Making
For implementation and evaluation the fall team will use the Plan-Do-Study-Act (PDSA). The PDSA
cycle allows the group to assess the outcomes of interventions and formulate changes based on data
(Langley, Nolan, Nolan, Norman, & Provost, 1996). JCAHO standards require and organization to have a
fall risk reduction program and continually monitor its effectiveness (JCAHO, 2006).
Method to Maintain a Successful Project Solution
According to Love (2008), theory-driven patient care improves patient safety and the professionalism
of nursing. Our nursing division philosophy is grounded on Jean Watson’s Theory of Human Caring with
the main concept being patient-centered care. Having a fall risk reduction program that identifies fall
risk and patient specific interventions is theory-driven and evidence-based practice.
The Rosswurm & Larrabee model will be used to guide nurses through the change in practice and
behaviors. According to Pipe (2007), this model is an implementation strategy that has been proven to
assist organizations with the successful application of introducing evidence-based practice. The model
has six steps to assist with the promotion of change: (1) assess the need for change, (2) link the problem
with interventions, (3) synthesize best evidence, (4) design practice change, (5) implement and evaluate
the change in practice, (6) integrate and maintain the change in practice.
Other important strategies to safeguard a successful project are: extensive education of all disciplines,
patient education materials, and having the appropriate safety equipment readily available on the units.
All interdisciplinary staff members that have patient contact will be educated on the fall prevention
program and their role in preventing falls. There must be least a 25% reduction in falls and 50%
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reduction in falls with serious for the project to be considered successful and maintained. The
interdisciplinary fall team will use the PDSA model to revise the program if the targeted goal is not met.
Dissemination of Findings
Results of this project will be presented at the Nursing Division’s leadership meeting, the Nurse
Practice Council, and Quality Council. Monthly results will also be posted on individual units in a visual
display that is easily understood by all staff members. If the project is successful and the data
considered reliable an article for publication may be written related to the process of developing a
collaborative interdisciplinary fall reduction program.
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References
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Silver Springs, Maryland.
Beasley, B., Patatanian, E. (2009). Developing and implementation of a pharmacy fall
prevention program. Hospital Pharmacy. 44(12 ), 1098-1102.
Chapman, J., Bachand, D., & Hyrkas, K. (2011). Testing the sensitivity and feasibility of four
fall risk assessments tools in the clinical setting. Journal of Nursing Management. 19(1),133142. doi:10.1111/j1365-2834.2010.0125x.
Fonda, D., Cook, J., Sandler, V., Bailey, M. (2006). Sustained reduction in serious fall related
injuries in older people in the hospital. The Medical Journal of Australia, 184(8), 379-382.
Hill-Rodriguez, D., Messmer, P.R., Williams, P.D., Zeller, R.A., Williams, A.R., Wood, M.,
Henry, M. (2008). The humpty dumpty falls scale: A case-control study, JSPN.14(1), 22-31.
Joint Commission on Accreditation of Healthcare Organization (2006). Top five sentinel
events by setting of care. January 2001 to July 2005. Retrieved from
http://www.jointcommission.org.
Kim, E., Monrdiffi, S.Z., Bee W., Devi, K., & Evans, D. (2007). Evaluation of three fall risk
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10.1111/j.1365-2648.2007.04419.x
Kristsonis, A. (2004). Comparison of change theories. International Journal of Scholarly
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Love, K. (2008). Interconnectedness in nursing : a concept analysis, Journal of Holistic
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Pipe, T. (2006, August). Optimizing nursing care by interpreting by integrating theory-driven
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Evidence based practice. Journal Nursing Quality Care, 22(3), 234-238.
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Clinical Innovations. 1(9). 1-33.
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Shuto, H., Imakyure, O., Matsumoto, J., Egawa, T., Jiang, Y.,Hirakawa,M., Kataoka,Y.,
Yanagawa, T.
(2010). Medication use as a risk factor for inpatient falls in an acute care hospital:
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Appendix A
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Post-Fall Analysis
Situation
1.
Time of day fall occurred:__________ Day of the week:___________
Length of hospital stay:________________(# of days admitted)
2.
Staffing: (Circle)
Full staff
Shift understaffed (explain):________________________________
Some unavailable due to ___________________(e.g., breaks,
emergency on unit)
3.
Where did the fall occur? (Circle)
Patient room
Bathroom
Hallway
Radiology or Test/Treatment
Environment
4. If fall occurred in patient room, circle items that were out of the patient’s reach:
Call light
Phone
Kleenex
Food tray
Waste basket Assistive device (cane, walker, glasses, hearing aid)
Other:____________________________________________________________________
5. Hazardous foot wear:
Yes
No
6. Trip Hazards? (Circle)
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Clothing
Obstructed path to bathroom
Tubing/cords None
Other:___________________________________________________________________
7. Evidence of slippery floor?
Yes
No
8. Was lighting adequate in the room?
Yes
No
9. Was there an equipment malfunction?(If marked yes equipment must be taken out of service
and work order placed)
Yes
No
Activity
10. What do we think this person was doing at the time of the fall? (Circle all that apply)
Getting up on own
Ambulating
Trying to go to the bathroom
Standing Up
Reaching for something
Toileting
Leaning on something
Sleeping
Chair
Wheelchair
Other:_________________________________________________________________
Ask the person: “What happened this time that was different
From all the other times you have done this
activity?:________________________________________________________________
Background
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11. Patient’s Primary Diagnosis :(Circle most applicable)
Neurological
Respiratory
Hematology/Oncology
Gastrointestinal
Infectious Disease
Renal
Metabolic/Endocrine
Cardiac
Ear/Nose/Throat
Unknown
Orthopedic
Psychiatric
12. Fall risk score:__________________________________________
Attach medication administration record for the 12 hours prior to the fall.
Assessment
13. Glucose result:______________________
14. Level of injury: (Circle one)
None (indicates patient did not sustain an injury)
Minor injury (indicates those injuries requiring a simple intervention)
Moderate injury (indicates injuries requiring sutures or splints)
Major Injury (indicates injuries that require surgery, casting, or further examination)
Death (that results from injuries sustained from the fall)
15. If patient has a bed alarm what zone was it set:______________
16. Fall categorized as: (Circle one)
Accidental
Anticipated physiological
Unanticipated physiological
Recommendation
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What can we do to prevent this from happening again? (Circle all that apply)
Increased rounding
Non-slip footwear
Oxygen tubing/IV tubing management
Hip protectors
Toileting plan
Pharmacy review of meds
Clear pathway to bathroom
Patient/family education
Remove clutter from the room
Have items close to patient
OT evaluation
PT evaluation
Alarm
Improved positioning
Other:___________________________________________________________________
Post-fall checklist
 Perform post-fall assessment and documentation to include: mental status, vital signs
including pulse oximetry, blood glucose, description of injuries noted from fall.
 Notify physician, nursing supervisor, and family
 Perform post-fall monitoring, including neurological checks if evidence/suspicion of head
injury
 Revise the plan of care to make patient high risk for falls to include prevention strategies
based on post-fall huddle findings.
 Document interventions to prevent patient from falling again
 Communicate fall and increased risk to next shift, other healthcare team members, family
if applicable
 Place falling star magnet on the door frame
 Re-educate patient/family on fall risk and document in medical record
 Complete this form and an incident report and give to the nursing supervisor
 Print MAR for 12 hours prior to fall and attach
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Appendix B
Patient
ID #
Patient
age
Date
of fall
Shift
of fall
Day
of
week
of fall
Location Activity Preof fall
at time fall
of fall
Morse
Fall
Scale
Length Level
of Stay of
Injury
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Key
Shift: 7a-7p= A, 7p-7a=P
Activity at time of fall: Ambulating=1, Getting OOB=2, Standing up=3, Sitting down=4,
Toileting=5, Sleeping=6, Chair=7, Wheelchair=8
Primary Diagnosis: Neurologic=1, Hematology/Oncology=2, GI=3, Infectious disease=4,
Respiratory=5, Cardiac=6, ENT=7, Renal=8, Orthopedic=9, Metabolic/endocrine=10,
Psychiatric=11, Unknown/other=12
Level of Injury: None=1, Minor=2, Moderate=3, Major=4, Death=5
Location of fall: Patient room=1, Hallway=2, Bathroom=3, Radiology/T&T=4
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.