After speaking with some former colleagues, it was brought to my attention that one of their current strategic initiatives is to address falls in the hospital. So … for fun, I decided to look at a few pieces of evidence-based peer reviewed (EBPR) literature to educate myself further. Many of the principles in the articles are not new. However, the information provides a good refresher in system analysis and uncovers the need for more substantial EBPR studies.
The purpose of this post is to hash out some existing fall literature, and to absorb some of the successful strategies that deal with falls from: problem identification to maintaining an effective program. I selected this review and study, because they were cited frequently, but more importantly they were free. Hopefully, I will gain access to some of the notable databases (DB’s) – like CINAHL, EBSCO, etc. – in the future. For now, we will look at places like Google Scholar and PubMed.
HOSPITAL FALL PREVENTION – HEPEL ET AL.
In the review – Hospital fall prevention: A systematic review of implementation, components, adherence, and effectiveness – Hempel et al. (2013) reviewed fifty-nine research studies – which were conducted over 28 years – to compile data regarding chosen the “implementation, components, comparators, adherence, and effectiveness of published fall prevention” interventions. These interventions included: staff education, establishing committees, seeking leadership support, and occasionally continuous quality improvement techniques (Hempel et al. 2013) .
In many cases, these interventions consisted of compounded interventions including: “…risk assessments (often not validated), visual risk alerts, patient education, care rounds, bed-exit alarms, and post fall evaluations). (Hempel et al. 2013) ” Documentation of these interventions were only consistent approximately 46% of the time with the existing documentation not always including the applied measures within the documentation itself.
High level study categories included: intensity of the implementation strategy, the complexity of the intervention, the information on fall prevention activities in the comparison group, and the level of adherence to the intervention. The criteria for rating each category were high, medium, and low.
The utilized care processes were classified using the following criteria: implementation strategies; intervention components for all patients; intervention components for high-risk patients only; comparator information; and adherence strategies and fidelity. Below is an outline of the interventions by category:
Implementation Strategies
- Staff education to raise awareness of fall prevention or training for specific tools
- Interdisciplinary team, task force, or other hospital committee established
- Piloting the intervention in selected units
- Activities to raise leadership awareness or gain support
- Continuous quality improvement techniques; Plan-Do-Study-Act, Institute for Healthcare Improvement spread framework
- Other implementation strategies
- No specified implementation strategy
Intervention Components for All Patients
- Patient and family education
- Care, safety, and toileting rounds
- Clutter-free and safe environment efforts
- Call lights within reach enforcement
- Non-skid socks and/or footwear
- Other intervention components
Intervention Components for High-Risk Patients Only
- Alert signs placed on beds, doors, patients’ records
- Bed- or chair-exit alarm system
- Identification wrist bands (“Fall Risk” bands)
- Care plan communicated at change of shift
- Moving high-risk patients close to nurses’ station or cluster
- Non-skid socks and/or footwear
- Care, safety, and toileting rounds
- Patient and family education
Comparator Information
- Alert signs placed on beds, doors, patients’ records
- No information on existing fall prevention measure
Adherence Strategies and Fidelity
- Audit and feedback on adherence to processes of care
- Monitoring and disseminating data on falls
- Fall prevention included in electronic health record
- Other adherence-promoting strategies
- No specified adherence strategy and no fidelity data
Less Common
- Designating a specifically equipped fall prevention room on the ward
The most prevalent fall risk scales from these studies included the following:
- ADAPT Fall Assessment Tool
- Berryman Predisposition for Falling scale
- Hendrich, Hendrich II Fall Risk Model / Assessment
- Innes Score; St Francis Memorial Hospital Standard Care Plan for the High-Risk Patient
- Schmid Fall Risk Assessment Tool
It was not always clear what measures were already in place when new measures were implemented. Additionally, there was overall poor reporting and documentation in these studies (less than 50% documentation in studies and even less that reported data). The data – that was reported – showed statistical heterogeneity. This means that the data was not consistent between studies in a way that was statistically unlikely to be marginal or accidentally disparate. The overall sentiment was perceived improvement; however, because of reporting – the results are not conclusive.
The takeaways from this review include: understanding the gaps in research studies, understanding the approach to addressing issues from a system level, and reviewing the standards currently being implemented.
ACUTE CARE HOSPITAL RANDOMIZED TRIAL – DYKES ET AL.
In the randomized control trial (RCT): Fall Prevention in Acute Care Hospitals – A Randomized Trial (Dykes, Caroll, Hurley, Et al., 2010), it was determined that implementing a fall prevention tool kit (FPTK) dramatically reduced the incidences of falls by one every four days. This decrease in turn, shared a decrease in fall-related injury.
The FPTK included the implementation of fall risk assessment, individualized care plans, staff education, and patient/family engagement. For the implementation of this kit, it was determined that a customized plan should be developed and custom tailored to the specific risk factor determinants. For instance, the research validated that falls occur at a higher frequency on geriatric unit. The tool was implemented with this in mind. Additionally, it was shown that the FPTK tool was not statistically effective in younger populations.
The study utilized the Institute for Healthcare Improvement’s Framework for Spread as an adherence method. As summarized by AI:
Key Concepts and Components
1. Preparing for Spread
- Leadership Commitment: Essential to initiate and sustain the spread plan.
- Readiness Assessment: Identify successful pilot sites and demonstrate the effectiveness of changes.
- Communication: Establish clear, early communication to engage stakeholders.
2. Establishing an Aim for Spread
- Target Population: Clearly define the clinics, units, or facilities involved.
- Specific Goals: Set measurable outcomes (e.g., reducing hospital mortality).
- Improvement Areas: Identify specific practices or protocols to be implemented.
- Time Frame: Set a realistic and achievable timeline (e.g., 6 months, 1 year).
3. Developing an Initial Spread Plan
- Communication Methods: Utilize organizational structures and communication channels effectively.
- Measurement System: Track progress and evaluate outcomes.
- Infrastructure Enhancements: Leverage existing systems and implement supportive changes.
- Transition Issues: Address potential barriers to adoption, such as lack of training or resistance to change.
- Operational Integration: Make new practices part of routine operations.
4. Executing and Refining the Spread Plan
- Monitoring Progress: Collect feedback regularly and adjust plans as needed.
- Knowledge Sharing: Promote learning from successful implementations and challenges encountered.
- Sustainability: Ensure practices are embedded into daily operations for long-term success.
(OpenAI, 2025)
Barriers to this RCT includes staff adherence, variance in unit practices, and potential reporting biases from care givers.
This study is more focused and supports a specific intervention – the FPTK. It is important to realize that by focusing on one intervention, it is easier to determine how the intervention specifically effects the problem without the influence of additional variables.
DISCUSSION
After reviewing the previous literature, there are multiple areas that effect the overall system level implementation and the success of each implementation. Further, measuring success is contingent upon the following:
- Understanding baseline interventions
- Selecting new interventions by focusing on the main risks of the population through data analysis
- Creating a plan that considers documentation, feasibility, adherence, and reporting
- Determine Key Performance Indicators (KPI’s), metrics, or variables for quantitative measurement
Once these items have been addressed, a strategic dissemination method must be developed, so that the plan can be properly implemented.
Next, it is important to select interventions. A Root Cause Analysis (RCA) must be performed on prior falls and near-miss events. In this way, interventions can be selected to address identified areas for improvement. Once interventions have been selected, and a plan has been developed, it must be properly disseminated to staff.
Some of the dissemination methods mentioned in these studies included: staff education to raise awareness of fall prevention or training for specific tools; Interdisciplinary team, task force, or other hospital committee established; piloting the intervention in selected units; activities to raise leadership awareness or gain support; continuous quality improvement techniques; Plan-Do-Study-Act, and the Institute for Healthcare Improvement spread framework. One of the desirable strategies mentioned is to incrementally introduce interventions by unit or area as a pilot.
To complete this process, data must be collected, analyzed and compared to areas where the interventions have not yet been implemented. After review, next steps can be determined.
After reading these studies, it is more evident that some of the issues hospitals face may be less about the selection of interventions and more about adherence. As a bedside nurse with some critical and intensive care experience, I believe that many nurses need to understand the “why” of interventions and see the outcomes of successful implementations. Additionally, just like patient-centered care, nursing education can be customized by including multiple learning styles. On a more micro level, trainers should seek to understand what motivates registered nurses and nursing technicians to effectively disseminate knowledge. Particularly, it is important to achieve communicating the “why” and aiming at motivation when communicating seemingly mundane and repetitive tasks.
References
Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., Meltzer, S., Tsurikova, R., Zuyov, L., & Middleton, B. (2010). Fall prevention in acute care hospitals: A randomized trial. JAMA, 304(17), 1912–1918. https://doi.org/10.1001/jama.2010.1567
Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., Shier, V., Saliba, D., Spector, W. D., & Ganz, D. A. (2013). Hospital fall prevention: A systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483–494. https://doi.org/10.1111/jgs.12169
OpenAI. (2025). ChatGPT (March 15 Version) [Large language model]. Retrieved from https://chat.openai.com/