Top 10 Contributing Factors(across all participating hospitals)

As a part of the Robust Process Improvement® (RPI®) methodology, the health care organizations measured their fall rate, fall with injury rate, and the contributing factors that led to patient falls. Contributing factors were identified and validated through statistical analysis using data from the hospital risk management reporting systems, individual patient chart review and patient/staff interviews.

Category Contributing Factor A B C D E F G

Bathroom Related/Toileting

Call Light

Education

Fall Risk Assessment

Hand-off Communication

Falls Culture

Patient fell while toileting

Medications that increase the risk of falls combined with toileting

Patient did not know, forgot or chose not to use call light

Fall prevention education to patient/family not used or inconsistent

Patient awareness and acknowledgment of their own risk for falls

Risk assessment tool is not a valid predictor of actual fall risk

Inconsistency in ratings by different caregivers

Medications that increase risk of falls combined with toileting

Inconsistent or incomplete communication of patient risk for falls between caregivers

Standardization of practice and application of interventions

Preventing Falls with Injury

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Top Contributing Factors and Solutions(across all participating hospitals)

Contributing Factor Categories Targeted Solutions

Patient fell while toileting

Medications that increase the risk of falls combined with toileting

Patient did not know, forgot or chose not to use call light

Fall prevention education to patient/family not used or inconsistent

Patient awareness and acknowledgement of their own risk for falls

Risk assessment tool is not a valid predictor of actual fall risk

Inconsistency in ratings by different caregivers

Inconsistent or incomplete communication of patient risk for falls between caregivers

Standardization of practice and application of interventions

Preventing Falls with Injury

• Implement hourly rounding with proactive toileting for all patients• Implement scheduled toileting for high risk patients: get patient up for toileting on a regular schedule

• Educate patients on medication side effects and increased risk for falls• Schedule medication administration for at least 2 hours prior to “bedtime”

• Educate patient on how to use and the need for using the call light for assistance at all times, especially when getting into/out of bed

• Revise patient/family fall precaution education packet and process. Education should be targeted and individualized to patient specific fall risks

• Implement a patient agreement form to use call light for all ambulation. Emphasize risk factors during education and signing of patient agreement

• Implement a “validated” fall risk assessment tool• Implement a standardized cognitive assessment tool • Integrate cognitive assessment tool results with fall risk assessment tool

• Standardize assessment tools used between nursing staff and physical therapy/ occupational therapy/rehab staff; allow both service areas to access each other’s charting detail in the Electronic Medical Record (EMR)

• Utilize white boards to communicate patient fall risks to all staff• Incorporate alerts into EMR that alert staff to patients who are at risk for fall and effectively translates fall risk information into useful tasks, reports and prompts• Initiate bedside shift report with patient that includes focus on fall risk concerns

• Implement house wide culture messaging around fall safety for all patients