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10 tips to prevent falls while you are in the hospital

 Tips to prevent falls

1. Use the call light when you need help.
2. Ask the nursing staff for help to and from the bathroom. This is very
important if you are unsteady. The call light in the bathroom may be
located on the wall.
3. For your safety, a member of the nursing staff may stay with you in
the bathroom.
4. If you take medicines that cause you to go to the bathroom often, ask
for help when you need to get up. Consider using a commode or
5. Some medicines may cause you to feel dizzy or sleepy. Take your time
getting out of the bed or chair. Sit at the edge of the bed for a few
seconds before you get up.
6. Wear nonslip footwear or slippers when you are up.
7. Wear your eyeglasses and/or hearing aid(s) when you are awake.
8. Walkers and canes can provide support. Other items do not. Do not
lean on the bedside table, furniture, IV pole or other items to steady
9. Ask a member of your health care team to place the call light, phone
and personal items within your reach before he or she leaves the
10.Tell a member of the nursing staff if you have any concerns about your

Tips for family and friends

The nurse identifies patients who may be at risk for falling with red
slippers and/or special signs.

Please speak up about safety concerns to the nursing staff. This includes
information about the risk of falling, or a recent history of a fall.

Patient safety and comfort are important to the health care team. Family
and friends can also help. Please read the information in this fact sheet so
you can remind your family member or friend of the 10 tips to prevent

You can also do the following.

11.Make sure the call light, phone and personal items are within easy
reach of the patient before you leave the room.
12.Call the nurse if the patient is weak or lightheaded.
13.Consider staying with the patient if he or she is confused or at a high
risk of falling.
14.Call the nurse before leaving the patient if he or she is confused.
15.Remind the patient to ask the nursing staff for help when getting up.

If you have any questions, please ask a member of your health care team.
Preventing Patient Falls in the Hospital
Falls are a common cause of injury, both within and outside the hospital setting. According to
the U.S. Centers for Disease Control and Prevention, more than one-third of adults over 65
fall each year. While not all falls cause injury, falls can be serious and may result in bone
fractures, excessive bleeding, or even death.
An estimated 500,000 falls happen each year in U.S. hospitals, causing 150,000 injuries.
Patients have a higher risk of falls if they:
 Have an impaired memory.

 Are older than 60.

 Have weak muscles or problems walking.

 Take drugs or a combination of drugs that make them sleepy.

 Use a cane or walker.

 Have chronic conditions.

 Need to use the bathroom frequently.

At JFK we use best practice evidence based processes to prevent patient falls. Every
hospital inpatient is assessed for their risk to fall. Special precautions are taken for patients
considered to be at a high risk to fall such as:
 Providing assistance when patients transfer in and out bed.

 Keeping the call bell in reach.

 Using a safety belt while in a wheelchair.

 Placing a yellow wrist band on the patient to alert staff that a patient is at risk of falling.

 A blue wrist band may also be used to as a reminder when a patient should not be left alone in the bathroom.

 Using non skid yellow socks.

 In some instances a bed alarm is used as an alert when the patient leaves the bedside without assistance.

Preventing falls is not simple. Fall precautions must be balanced with other patient care
considerations such as minimizing restraints and promoting mobility.
Keeping patients safe by preventing falls is one of our highest priorities.


We define a fall as any sudden, uncontrolled, unintentional or intentional dropping downward

from a standing, sitting or lying position that results in landing on or contact with a surface or
object. This includes instances where a staff member is present and intervened to prevent
We track all patient falls including those without injury and where a staff member was
present and assisted the patient to the floor to prevent injury.
The graph shows a rate of inpatient falls. The rate is determined by dividing the number of
falls by the number of patient days and multiplying by 1000. This rate is an industry


This graph shows that our efforts to prevent patient falls are working. The downward trend
line shows that fewer patients are falling. However, we continue to work to reduce falls by
staying current with best practices and reviewing all falls. This allows us to find opportunities
to enhance our fall prevention program.
Keeping patients safe by preventing falls is one of our highest priorities. Our goal is to
eliminate injuries from falls.


Patients, families and visitors have an important role in preventing falls. You can help avoid
falls by:
 Making sure that needed personal items as well the the call bell are within reach.

 Not leaning on furniture or using the IV pole for support.

 Always using the call light before getting out of bed for any reason.

 Wearing the non skid yellow socks.

 Sitting at the bedside and standing slowly when getting out of bed.
 Not interfering with bed alarms.

Patients as well as their families and visitors are essential members of the health care team
and can help avoid falls. Printed information on the prevention of falls is given to each new
patient. Patients and their families should read this important information. In addition, there
are poster board presentations on patient care units that provide information about fall risk
assessments, requesting assistance, and strategies to prevent falls.
Additional information about how you can prevent hospital patient falls and falls outside the
hospital at this Agency for HealthCare Quality and Research

The No-Fall Zone

Nobody can prevent all patient falls, but hospitals are significantly reducing the ones they
June 1, 2013

Lola Butcher

As the federal government urges hospitals to double-down on patient-safety issues,

the 12-bed cardiac telemetry unit at Essentia Health in Fargo, N.D., is doing its part.

Between January and September of last year, the unit's fall rate decreased from
seven falls per 1,000 patient days to 2.4 falls. And the unit is working toward
perfection. "Right now, as we speak, we are at our record number of days without a
fall, which is 69 days," house supervisor Tina Kraft, R.N., said earlier this spring.

While not every

patient fall is preventable, hospitals around the country are proving that the right
combination of technology, care processes and focus can reduce the number of falls
significantly and, more importantly, the injuries to patients they often cause.

Androscoggin Valley Hospital in Berlin, N.H., a 25-bed critical access hospital, has
not had a fall with serious injury in more than three years, and falls of any kind have
become extremely rare. "We go months now where we have zero falls, which we just
never, ever hoped could happen," says Clare M. Vallee, R.N., vice president of
nursing services.

The scope of the problem

That's saying something. Falls remain one of the most vexing patient-safety
problems facing hospitals. While patient falls are rare events, they often cause
injuries and even death, as well as additional costs.

Between 700,000 and 1 million patients fall in hospitals each year, according to
the Agency for Healthcare Research and Quality. While the majority of patients who
fall are not seriously injured, the toll of fall-related injuries is hefty. The Joint
Commission reports that the average increase in a hospital's operational costs for a
serious fall-related injury is more than $13,000, and the patient's length of stay
increases by an average of 6.27 days.

Framing the Issue

 Between 700,000 and 1 million patients suffer a fall — an unplanned descent to the
floor with or without injury — in U.S. hospitals each year, according to the Agency for
Healthcare Research and Quality. Between 30 and 51 percent of falls result in an
 Since 2008, the Centers for Medicare & Medicaid Services do not pay hospitals for
the extra care associated with an inpatient fall and the trauma associated with it.
 While many falls can be avoided, fall prevention is complex because so many things
are associated with falls. These include patient factors — including weak muscles,
chronic conditions and use of a cane or walker — as well as environmental factors,
such as beds not positioned at an optimal height, and process-of-care factors, such
as nurses not responding promptly to call bells.

The challenge of fall prevention is increasing as the inpatient population ages. Both
the overall risk of falling and the likelihood of being injured from a fall increase as
people age. Falls expert Pat Quigley, at the James A. Haley Veterans' Hospital in
Tampa, Fla., points to Centers for Disease Control and Prevention data that show 22
percent of patients are now 74 years or older; people in that age range are at a high
risk for repeat falls, fall-related injury and complications after a fall. Indeed, research
shows that older patients do not even have to sustain an actual head strike for
microvessels around the brain to tear, resulting in serious problems, she says.
"Even if you think there is no injury or a minor injury, that patient can still have grave
consequences," Quigley says.

Since 2008, patient falls with injury have been included in the Centers for Medicare &
Medicaid Services' list of hospital-acquired conditions for which providers will not be
reimbursed. The financial implications for hospitals increase in the federal fiscal year
that begins Oct. 1, 2014, when hospitals with high rates of hospital-acquired
conditions receive a 1 percent cut in Medicare payments for all discharges.

How to count falls

Veterans Administration researchers recently reported that the rate of falls in acute
care hospitals ranges from 1.3 to 8.9 per 1,000 patient days. Viewed another way,
the national rate is 0.562 falls per 1,000 discharges, according to CMS data reported
on Hospital Compare.

While hospitals should track their total fall rate and work to keep reducing it, Quigley
says an analysis with more precision is essential to a successful fall prevention

She encourages hospital executives to categorize falls into four types: accidental,
anticipated physiological, unanticipated physiological, and behavioral or intentional
[See Page 27].

The first two types of falls are generally preventable; the second two are not. "You
can't prevent all falls. That's the bottom line," Quigley says. "That's the myth that we
have to dispel."

By tracking falls in the two categories that can be prevented, hospitals can tailor their
interventions appropriately. "If I'm leading a hospital and 80 percent of the falls that
are occurring in my hospital are accidental falls, then I have an issue with the safety
of my care environment, and I need to do something about that," she says.

Those interventions, however, are different and distinct from those needed to treat
known risk factors to reduce anticipated physiological falls. Patients with intrinsic risk
factors such as high-risk medications or weak muscles require an individualized plan
in which all caregivers address those patient-specific challenges.

"Universal fall precautions and interventions based solely on an [assessment] scale

score or level of risk are not effective," Quigley says.

How to stop falls

Unlike hospital-acquired infections, which can be addressed by adopting evidence-
based protocols relevant to all hospitals, there is no bundle of prevention practices
that has been proven to eliminate all falls. However, multifaceted fall prevention
programs have been shown to reduce the relative risk for falls by as much as 30

In a review of fall prevention programs, Isomi Miake-Lye and her colleagues at the
Veterans Affairs Greater Los Angeles Healthcare System found several
themes associated with successful fall prevention programs: leadership support;
front-line staff engaged in program design; a multidisciplinary committee to guide the
program; pilot-testing interventions; use of information technology to provide data
about falls; staff education and training; and convincing staff that falls can be
"Changing the prevailing nihilistic attitude that falls are 'inevitable' and that 'nothing
can be done' is required to get buy-in to the goals of the intervention," the authors

That "nothing works" attitude is being challenged by several national initiatives

targeting patient falls. Earlier this year, ARHQ issued "Preventing Falls in Hospitals:
A Toolkit for Improving Quality of Care," which identifies best practices for preventing
falls by high-risk patients and accidental falls.

Also new this year: The Institute of Healthcare Improvement updated its
"Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from
Falls," which focuses on anticipated physiological falls.

Meanwhile, thousands of hospitals around the country are focusing renewed energy
on fall prevention strategies through their participation in Hospital Engagement
Networks, or HENs. Hospitals participating in a HEN are focused on the 10 patient-
safety priorities set by the CMS Partnership for Patients campaign.

"Falls are one of those topics that are pertinent to almost every hospital, and one that
most hospitals are seeking to work on actively," says Beverly Ranstrom, HEN project
manager for the North Dakota Health Care Review Inc., the state's quality
improvement organization.

North Dakota is one of 31 states participating in the American Hospital Association's

Health Research & Educational Trust HEN. Representatives from 30 North Dakota
hospitals met last year to develop action plans for their patient- safety goals.

Most hospitals that are focusing on fall prevention looked first to see if patients were
being assessed for their risk of falling and if the information from those assessments
was being used. "Are the assessments done on admission and then forgotten? Or is
the assessment carried on from shift to shift?" Ranstrom says. "A lot of hospitals
started out with that, but, as they got into it a little more, they looked at some of the
other interventions that were being discussed by HRET and through Listserv, such
as intentional rounding or providing interventions based on the risk assessment."

Processes to the rescue

When the nurses who work in Essentia Health's cardiac telemetry unit learned of the
unit's high fall rate in the first quarter of 2012 — seven falls per 1,000 patient days —
they came to a quick consensus that a staff shortage was the culprit. They believed
falls were most common for confused patients who need sitters, which were
sometimes unavailable; that most falls occurred on nights and weekends when fewer
staff were on duty; and that a higher nurse-to-patient ratio would reduce falls.

However, data presented by the hospital's performance improvement staff shot that
thinking down. It showed that more than 70 percent of falls occurred during the day
shift and the majority of patients who fell were charted as "alert and oriented."
"It was a pretty big eye-opener for the staff," Kraft says. "They were ready to listen
and make some changes and be accountable."

They launched a multifaceted attack on patient falls that started with transparency.
Hourly "rounding with reason" — asking each patient specific questions to identify
their needs at the moment — was already in place and nurses were supposed to
report what they did on each round on a sheet in the patient's room. But compliance
was not good. "We started to keep track of the staff who were completing these
[hourly rounding] sheets and posting them in our break room to show which staff
were pulling their share," Kraft says. Very quickly, documented completion of hourly
rounds doubled.

Meanwhile, a sign reporting the number of days since the last patient fall was posted
in a common area to be seen by patients, families and anyone else on the unit.
Although it was controversial among nurses at first, it has become a learning tool.
"When we have to turn it back to zero, nurses start asking, 'What happened?' and
'What day did that happen?' " Kraft says.

Other steps include:

Expanding the huddles. At the beginning of each shift, nurses huddle with unit
secretaries, primary care physicians and ancillary staff to go over the fall risk for
each patient on the unit.

Color-coding. Each patient's risk of falling is written in color on the dry-erase board
in his or her room so it stands out. The board also lists precautions pertinent to that
patient, such as a bed alarm, chair alarm or the need for two people to move the
patient. "If anybody walked into that room, they would know what that patient
needed," Kraft says.

Teaching back. Recognizing that some patients did not understand how to use the
nurse call light, Essentia Health began using the teach-back method in which the
patient demonstrates how to use the call button. That increases the likelihood that
patients will call for help rather than trying to get out of bed on their own.

After-fall protocols. After a patient falls, a staff huddle is convened to discuss what
happened and identify possible causes. The nurse responsible for the patient also
fills out a questionnaire so the unit continually gathers and analyzes data about
patient falls. "We actually found that the majority of falls — at least 75 percent —
were because a bed alarm or a chair alarm was not turned on," Kraft says. "That is
something simple that can be done."

Technology to the rescue

The AHA/HRET HEN uses a collaborative model that encourages all participating
hospitals to share their patient-safety learning, which is why a critical access hospital
in New Hampshire has become a national poster child for fall prevention success.
Historically, Androscoggin Valley experienced about 15 to 20 patient falls each year,
with one or two of those causing serious injury. Attempts to reduce falls had not
worked. The turning point came in 2009 when the hospital replaced its old call bell
system with newer technology that incorporates wireless staff phones and hallway
monitor screens.

"When a call bell goes off, when a chair alarm goes off, when a bed pad alarm goes
off, the alert immediately goes to the phones and to the wall screen," Vallee says. If
the staff member responsible for that patient is busy, the message is rejected, which
sends it to another staff member until someone responds.

The system also reminds nurses to do hourly rounding and the display screens,
which are visible throughout the unit, report on which rooms are overdue for rounds.
"If the unit coordinator looks up and sees that a patient in Room 448 needed to be
rounded on six minutes ago, she will get up and do the rounding," says Jean Wolf,
director of quality and patient safety. "It allows more teamwork and delegation and

Most importantly, it means rounds get completed more frequently, and that extra
contact with patients has eliminated injury-producing falls for more than three years.

Putting it all together

Although fall prevention is complicated, focused efforts do pay off: The HRET HEN
reported a 6 percent relative risk reduction in falls for 325 participating hospitals in

That translated into an estimated $16 million in cost savings from avoided falls
during the year.

Senior Director Charisse Coulombe expects the risk reduction and savings to be
significantly higher by the end of this year. "We believe we are off to a good start,"
she said. "And we know the hospitals are really continuing to gear up to try different
things to prevent the falls from occurring.".

— Lola Butcher is a freelance writer in Springfield, Mo.

Executive Corner
Fall prevention is one of the 10 focus areas of the Partnership for Patients, a public-
private initiative of the Centers for Medicare & Medicaid Services. One of its
overarching goals: a 40 percent decrease in preventable hospital-acquired
conditions — including trauma from patient falls — by the end of 2013 compared
with 2010.
To pursue that goal, the partnership contracted with 26 Hospital Engagement
Networks, or HENs, the largest of which is convened by the AHA's Health Research
& Educational Trust.

The AHA/HRET HEN has teamed with 31 state hospital associations that are
working with 1,600 hospitals in a collaborative effort to work toward the partnership's
goal. Charisse Coulombe, senior director of the HRET HEN project, says the HEN
provides an array of resources and services to help hospitals improve patient safety
by reducing falls.

- The Improvement Leader Fellowship program. Participating hospitals send

individuals for training on the Institute for Healthcare Improvement's quality
improvement methodology and the skills needed to be a change agent in their

- "Change packages" that provide how-to information about proven changes that
have helped hospitals to reduce falls.

- Experts to help troubleshoot when quality improvement efforts are not working.
"The subject matter experts know the falls topic like the backs of their hands and can
help them come up with maybe a slightly different idea, or totally new idea, or just a
quick modification so that it can fit into the culture for that hospital," Coulombe says.

- Site visits to help hospital fall prevention teams plan, implement and analyze their
quality improvement projects.

- An active Listserv for peer-to-peer sharing about the challenges and successes of
fall prevention initiatives.

- Data collection and analysis that help hospitals know whether they are reducing
falls and, if so, which interventions are responsible for the improvement.

How to reduce injuries from fall

Although there is no evidence-based bundle of practices to prevent injury-inducing
falls, the Institute for Healthcare Improvement has identified six promising changes
to reduce them.

1 | Screen risk for falling on admission.

2 | Screen fall-related injury risk factors and history upon admission.

3 | Assess risk of anticipated physiological falling and risk for serious injury from a

4 | Communicate and educate staff and patients about patients' fall and injury risks.
5 | Standardize interventions for patients at risk for falling.

6 | Customize interventions for patients at highest risk of fall-related injury.

Source: Institute for Healthcare Improvement, 2012

Four categories of falls

Falls expert Pat Quigley, from the James A. Haley Veterans' Hospital in Tampa, Fla.,
encourages hospital executives to categorize patient falls into four types. The first
two types of falls are generally preventable; the second two are not.

•Accidental: These falls occur when low-risk patients trip over an IV pole, fall out of
bed when they reach to get something or encounter another environmental hazard.

•Anticipated physiological: The most common type of patient falls, these occur in
patients who have risk factors that can be identified in advance, including abnormal
gait, high-risk medication, urinary frequency or dementia.

•Unanticipated physiological: These falls occur in patients who have a low risk of
falls in general but suffer an event — a seizure, stroke or fainting episode — that
results in a fall that could not have been predicted.

•Behavioral or intentional falls: These occur when a patient acts out.