Déjà Vu in Health Care: Preventing Patient Falls


To work in health care is to be involved in patient fall prevention. It’s an ongoing plan of process improvement. To this end, health care organizations launch task forces, allocate resources, implement new leading practices and establish metrics to measure performance. The expectation is that appropriate precautions are being taken to eliminate patient falls. Unfortunately, déjà vu can still occur: falls continue to happen, both with injuries and without.

Falls are the most commonly reported adverse event in hospitals. Between 700,000 and 1 million hospitalized patients fall each year, and approximately one-third of them sustain injuries, according to a June 2017 report from the Agency for Healthcare Research and Quality. An October 2016 report showed that a serious fall with injury was calculated to cost a hospital an average of $14,056 per patient and result in an additional 6.3 hospital days per patient.

“There is always more to learn about this topic,” said Jessica Schoenthal, RN, MSN, CPPS, collaborative advisor at Vizient. “Contributing factors vary in each case, which can increase the complexity of finding solutions. Active and consistent patient and family engagement is a key element to preventing patient falls. It is also important to evaluate fall event commonalities and determine preventative interventions to positively impact outcomes.”

Hospitals can support fall prevention strategies (and avoid déjà vu) by providing regular updates and reminders to staff on best practices. This is essential since the health care team must continually balance competing priorities when managing patients.

Predicting falls: Choosing tools and prevention champions

A patient’s risk of falling and risk of injury from a fall should be evaluated as soon as possible upon admission and at regular intervals while admitted through a screening or assessment tool. A screening tool is a binary (yes-or-no) instrument that gives the clinician a positive or negative indication for a potential patient fall. An assessment tool may include a determination of fall risk as well as the degree of risk, such as low, medium or high.  

Results of evaluations for fall risk and injury completed by staff can vary based on the person’s knowledge of the tool, their available information and critical thinking skills. Education for new hires, and regularly scheduled refresher training for current staff can improve the reliability of the results obtained from a fall risk evaluation.

“Reducing and eliminating patient falls is not a nursing-only initiative. All members of the health care team should be included in daily plan communications,” Schoenthal said.

Organizations that have successfully sustained a reduction in falls have made fall prevention and patient safety a priority at all levels, from housekeeping and dietary staff, to nursing, clinical providers and leadership teams. In addition, designating fall-prevention champions across various hospital units can provide staff with real-time knowledge-sharing, improved assessment skills and use of appropriate fall-prevention interventions.

Fall screening and assessment tools are the first step in partnering with the patient for his or her safety. The second step is to identify patient-specific interventions that will prevent falls. Brigham and Women’s Health created an online program, Fall T.I.P.S. (Tailoring Interventions for Patient Safety). As described on its website, “Fall TIPS is a novel, evidence-based program that is becoming a standard for engaging patients and families in the three-step fall prevention process.” It’s designed to facilitate conversations between the care team and patient to identify risk factors and appropriate prevention techniques.

“Each patient care plan should be individualized with ongoing multidisciplinary collaboration to support success. Confusion among the staff may result if the patient care plan is not cohesive or if team communication breaks down due to staff silos,” said Schoenthal. “A per-shift huddle can help identify at-risk patients and communicate fall-related learnings and information. Fall-risk assessments and patient-specific interventions to prevent falls should be included during transitions of care and shift-to-shift handoffs.”

Other recommendations: Write the patient’s recommended activity level on the bedside whiteboard. Utilize a “falls note” template, color-coded chart flags and a list of fall risk factors that may be hard-coded into your hospital’s EMR. Environmental and logistical modifications can also facilitate better prevention. Suggestions include:

  • Video monitoring
  • Alarm systems
  • High-impact floor mats
  • Helmets
  • Gait belts
  • Color-coded socks
  • Color-coded signs in rooms
  • Fall-risk bands or bracelets
  • “Call don’t fall” signage

Preventing falls: Patient-centered, family-involved

The patient and family are essential members of the multidisciplinary fall-prevention team. They should be included during the initial evaluations and when determining the interventions to be used throughout all phases of care and during handoffs. The patient and family members should be encouraged to speak up if there are concerns about a patient’s mobility, mental capacity and/or home environment.

“With elderly patients, staff can build trust by emphasizing that patients of all ages are susceptible to falling, not just one population,” Schoenthal said. “It’s important to explain that a lack of familiarity with surroundings and contributing medical conditions, such as low platelets or osteoporosis, can also increase the risks of falling and possible injury.”

As with all process improvement and safety initiatives, leadership is critical to success. Policies and procedures should include definitions, procedures and reporting mechanisms to be used for communicating incidents of patient falls. Conversely, patient units that achieve a reduction or elimination of patient falls should be rewarded and communicated across the organization.

Though a patient fall may feel like a déjà vu moment for staff, it has root causes. Working with patient safety and nurse managers, the multidisciplinary team should follow outlined procedures to investigate and uncover unknown or unresolved questions: Were there staffing issues? Were environmental factors left unattended? Were there equipment-related issues? Was incomplete or nonexistent communication a factor? The answers will often be challenging to the team, but if resolved, the overall culture of patient safety and patient outcomes will improve.

More information is available

“The Vizient Patient Safety Organization convened a group of health care leaders who have successfully implemented fall-prevention programs,” Schoenthal said. “Their collective knowledge was captured in a succinct, easy-to-use ‘falls binder’. The content is designed to build upon a multidisciplinary team’s knowledge and offer actionable information and self-assessments that may be used immediately.”

The patient-centered, fall-prevention virtual binder is available here. For more information about patient safety, contact

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