A Customized Approach to Preventing Inpatient Falls

Inpatient falls can have devastating consequences. Thirty percent of falls result in serious injury, and falls are the leading cause of injury-related death in patients age 65 and older. In hospitals, falls are the second most common adverse event after medication errors. Traditional fall prevention programs have delivered mixed results at best. A study conducted at Partners Healthcare System suggests that protocols that do not target specific factors that put individual patients at risk may not yield sought-after results.

Although The Joint Commission has made reducing the risk of patient injuries from falls a national patient safety goal, widely used universal fall prevention programs have demonstrated only limited success. Some believe it is because traditional programs use nonvalidated risk assessments and apply precautions universally, an approach that lacks acknowledgment of individual patient needs. Only a few hospitals, such as Partners Healthcare System, have tailored prevention tactics to individual patient needs.

Partners Healthcare System assembled a fall prevention task force to customize its risk assessment procedure and develop a fall prevention toolkit that would enable healthcare providers to tailor an individual fall prevention program for each patient deemed to be a fall risk. The task force first conducted a literature review of assessment tools and decided on the Morse Fall Scale as its fall risk assessment tool. An annual competency training program was developed to teach nurses to use the tool correctly. The hospital received a Robert Wood Johnson Foundation grant to fully develop the toolkit and evaluate outcomes.

Task force members worked with the IT staff to develop computer software that housed the Morse Fall Scale and included a menu of prevention strategies. Individualized fall prevention steps could be matched to each patient if appropriate to the patient’s needs. The task force also created a care plan, patient handout, a bed poster, and illustrated icons that depict various fall prevention methods. Three nurse champions helped to develop and test the software and train nurses on their units to use it.

The Toolkit in Practice

In the study, which included more than 10,000 patients, nurses on selected units used the toolkit to assess each patient’s fall risk and then customize interventions that targeted the patient’s specific risks. The nurse would complete a computerized fall risk assessment—on admission, at each shift change, and with each change in patient status—and receive a computer-generated list of recommended patient-tailored interventions. The software also generates a customized fall prevention care plan, educational handout, and bedside alert poster.  The care plan lists the patient’s risk factors and prevention strategies. It is placed in the patient’s chart and is automatically incorporated into the interdisciplinary care plan. The nurse can review the educational handout with the patient and family members. A poster is placed above the patient’s bed to alert caregivers and visitors to the patient’s risk of falling and includes up to six icons, each depicting a specific fall prevention strategy.


Findings from the study indicate that the toolkit reduced falls. On units where the toolkit was implemented, 67 patient falls (2.76 falls per 1,000 patient days) occurred compared to 87 falls (5.05 falls per 1,000 patient days) on other units.  For patients age 65 and older, the difference in fall rates was greater. Those units that implemented the toolkit also saw a small decline in falls that caused injuries in patients over age 64. On average, units using the toolkit experienced a fall rate well below their state’s mean of 3.99 falls per 1,000 patient days.

Hospital administrators plan to roll out the toolkit systemwide, using it to replace existing fall risk assessment procedures.

To learn more about fall assessment and prevention, check out Mosby’s Nursing Consult: Quality and Safety— CMS Never Events.

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