Adverse Event Falls with Harm

Prevent #Falls with Harm

Hospitals have a responsibility to keep their patients safe. Falls are common adverse events in acute care hospitals. Hospitalized patients fall 2-3% each year and 30-51% of falls result in injury. Falls are a burden for patients, families and hospitals. Falls affect the physical and psychological health of patients through pain, injuries, immobility and decreased function. Complications from falling lead to longer hospital stays, a loss of independence and have a significant financial cost. Although a falls prevention strategy has been implemented within the hospital, the results indicate that there has not been a reduction of the number of falls with harm. We are interested in understanding if anyone has been successful in decreasing falls with harm for hospitalized patients.


Shared Governance


Engaging Physicians in a New Communication Curriculum

Participant comments on Adverse Event Falls with Harm

  1. At our Organization, we implemented several initiatives around reducing falls with harm. Two key initiatives are hourly nurse rounding and bedside communication handoff. Both have had a positive impact on reducing falls with harm (we have seen a 40% reduction year over year in falls with harm).

    1. Hello
      How did you get the buyin from the nurses to sustain the purposeful rounding? Brenda

  2. At our organization ,In May 2012, the adult Bone Marrow Transplant Unit (BMT) grieved after a sentinel event were we lost a patient as a consequences of fall related injury, the hospital decided to act seriously on creating a robust falls prevention program, that can cover all age groups and prevent harm resulted from fall.
    The collaborative team was led by nursing staff from the adult BMT unit, and included a multidisciplinary team from several departments such as, Medical, Pharmacy, Physical Therapy, Nutrition, patient and family Education, and Quality and patient safety staff. This step was the consolidation in the program were all relevant parties put their hand on the gap that required the improvement and the latest EBP on how to fix it.
    The below are some examples of the actions done in each of the PDCA cycle:
    • Set a goal oriented project charter and approve it from all team players
    • Define a time frame for each suggested action and approve it in a time schemed gantt chart
    • Design a structural gap analysis survey and perform safety pulse check on the essentials for fall prevention in patient care environment
    • Monitor the Nursing Quality Indicator falls indicators on quarterly basis
    • Analyze all Adverse occurrences and perform Root Cause Analysis that indicates the potential fall reasons and risk factors
    • Perform the Environment of care survey by qualified and trained staff on all the piloted units in the adult medical and oncology/ hematology units
    • Data was shared with the team members and presented to hospital safety committee
    • Recommendations of the survey were communicated from the chief Operating Officer to the project management department for implementations of structure change
    • Policy and procedure changed to include : EBP fall assessment tool ( Morse for adult patient and Humpty Dumpty for children) , post fall care algorithm, role of pharmacy, PT and Dietician in the fall prevention,
    • Develop a patient education booklet in both languages to educate patients and family on fall prevention within hospitals
    • Develop posters for fall prevention in the toilet and post them in each patient toilet
    • Introduce and implement fall assessment care planning to manage high risk to fall patients
    • Educate staff on reporting Adverse occurrences of falls.
    • Include the fall project in all the units’ based council agendas in all piloted units and the divisional and hospital wide nursing quality councils
    • Introduce none-slippery footwear to be used by all at risk patients.
    • Educate staff nurses on the cultural aspect of fall prevention and the required modification in the care schedule and plans to overcome patient cultural and religious practices and exhibit the respect to those by Check:
    • Continuous monitoring falls indicators ( Falls and falls with Injury quarterly
    • Continuous RCA evaluation of all adverse occurrences of falls
    • Audit the compliance with falls assessment, care planning and education quarterly
    • Apply policy and procedure in all hospital units
    • The hospital is currently consistently below the 25% in falls with injury in all hospital units.


  3. Update
    We have 95% improve in reduction in 2017.


    1. Hello Amal
      These are amazing results. Did you trial alarming devices that sound when the patient exits their bed or chair?

  4. At our Organization, we implemented a PI (Performance Improvement) project using PDCA Cycle. This project helped with our Fall rate significantly.
    •Using the Performance Improvement method “Plan-Do-Check –Act (PDCA), the Fall Prevention campaign was implemented focusing on preventing patient’s falls and its related injuries
    •Posey vests discontinued
    •Voice-activated bed alarms promoted
    •Soft belt restraints added to inventory
    •Staff educated on minimizing restraint product use
    •Policy on falls and safety revised
    •Patients and family members were educated
    •Hourly Rounding with purpose implemented
    •“Call Don’t Fall” signs posted in different languages in patient’s rooms
    •Reduced use of agency staff
    •Confused patients assigned rooms closer to nurse’s station
    •Night staff assigned temporary work stations closer to patient rooms
    •Improved Nurse-Patient ratio for night shift

    •Measures of success evaluated through monthly unit-based patient fall reports, direct observation, post-fall investigation forms review and comparison with NDNQI benchmarks

    •Post-fall investigation form revised to include post-fall “huddle”
    •Exploration of additional product resources such as chair alarms, etc.
    •Patient Safety education sheet related to fall prevention.

    •An observable decrease in patient fall rate from initial 12.8 % to the set benchmark provided by National Database on Nursing Quality Indicators (NDNQI) of below 3.5 falls /1000 patient’s days after implementing Performance Improvement method “Plan-Do-Check –Act (PDCA) process. This is seen in our present practice as shown below.

    1. Hello Ruth
      What is the new nurse-patient ratio for the night shift. How did you evaluate the effectiveness of this initiative?

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