Preventing Falls and Fall-related Injuries in Health Care Facilities

Falls with serious injury are consistently listed as one of the Top 10 Sentinel events reported to the Joint Commission Sentinel Event database. While extensive clinical research and evidence-based strategies in fall prevention exist, reducing injurious falls in the hospital environment remains difficult. Several factors contribute to falls such as variation in assessment tools to identify fall risks, ineffective communication and handoffs, inadequately individualizing a patient’s plan of care and physical environment.

Literature review shows that close to one-third of falls can be prevented. A high-reliable and sustainable fall prevention program includes:

  • Patient and family engagement.
  • Executive-leadership sponsored interdisciplinary fall reduction committee.
  • An evidence-based comprehensive fall risk assessment tool.
  • Communication and educational plan for all staff.
  •  Post fall management.

Getting Started

WSHA has created a variety of tools and evidence-based resources to guide members in an effective and sustainable fall prevention program. Whether you are looking at fundamental components for a sustainable program infrastructure or your facility has an established program and you looking at program enhancement, begin with a high-level overview utilizing WSHA’ s Fall with Injury Prevention Top 10 Practices and the Organizational and Unit Level Gap Analysis Tool.

Organization and Unit Level Gap Analysis Tool

Safety Action Bundle Strategic Planning Tool  

Safety Action Bundle

Fall Risk Factor Assessment Tools

Fall T.I.P.S:  Fall Prevention Toolkit

Hendrich II Fall Risk

Johns Hopkins Evidence-Based Fall Safety Initiative

Johns Hopkins Fall Risk Assessment Tool for Acute Care

Johns Hopkins Fall Risk Assessment Tool for Home Health Care

Morse Fall Assessment User Guide

Toolkits & Resources

Post Fall Management

Post Fall Management is essential to maintain a patient’s safety, as well as an opportunity for a healthcare facility to identify key learning about how to prevent future falls.

WSHA has developed evidence-based tools to support Post Fall Management. The Post Fall Huddle Assessment Tool supports hospital staff, patients and their family in a safe learning environment to understand why a fall occurred, determine the risk factors that caused the fall and assess patient injury., Patients and family support the clinical team in identifying immediate opportunity to prevent a recurrent fall . The Post Fall Audit Tool evaluates the effectiveness of the Post Fall Huddle and provides hospital leadership feedback on the effectiveness and reliability of the process as well as opportunities to maintain sustainable program attributes.

Post Fall Huddle Tool 

Post Fall Audit Tool

 

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Washington State Hospital Association
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