R E V I E W S & A N A LY S E S Falls Prevention: Pennsylvania Hospitals Implementing Best Practices Michelle Feil, MSN, RN INTRODUCTION* Senior Patient Safety Analyst Pennsylvania Patient Safety Authority In December 2011, the Pennsylvania Patient Safety Authority partnered with the Hos- pital and Healthsystem Association of Pennsylvania to lead the Pennsylvania Hospital Engagement Network (HEN) Falls Reduction and Prevention Collaboration. This collaboration is funded by the Partnership for Patients initiative established by the ABSTRACT Center for Medicare and Medicaid Innovation (also known as the Innovation Center). Between January and May 2012, 83 hospitals from across the commonwealth joined The Pennsylvania Patient Safety Author- the collaboration and enrolled in the Pennsylvania Patient Safety Reporting System ity provided 83 hospitals participating (PA-PSRS) Falls Reporting Program. in the Pennsylvania Hospital Engage- ment Network (HEN) Falls Reduction A major focus of the collaboration continues to be to ensure that hospitals are imple- and Prevention Collaboration with two menting evidence-based practices in falls prevention. Education provided to hospitals tools to evaluate their falls prevention in the collaboration has included a review of what is currently established as best prac- programs: a self-assessment survey and tice based on individual, high-quality research studies and systematic reviews, as well as a process measures audit. The survey evidence-based falls prevention guidelines.1-9 results revealed two categories of best The Authority developed two tools for hospitals in the collaboration to use in evaluating practices with high levels of full imple- their falls prevention programs: the Hospital Engagement Network Falls Reduction and mentation: event reporting and postfall Prevention Collaboration Self-Assessment Tool (SAT) survey and the Falls Prevention assessment. The three categories of Process Measures Audit Tool. As a result of facilities using these tools and sharing their best practices with the lowest levels of findings, the Authority has been able to (1) identify which best practices in falls preven- full implementation were medication tion are being included in participating hospital falls prevention programs, (2) measure review, communication, and use of sit- compliance with implementation of best practices, and (3) identify specific falls preven- ters. Comparing survey responses with tion best practices associated with higher or lower rates of falls with injury. The falls SAT the audit results revealed a noticeable survey and the Falls Prevention Process Measures Audit Tool can be accessed at http:// gap between levels of full implemen- patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Pages/home.aspx. tation of best practices reported on the survey and compliance with falls METHODS prevention practices observed during the audit. Analyses of survey results Falls SAT Survey and hospital rates of falls with injury The falls SAT survey was adapted from an existing questionnaire10 and was designed identified 35 individual falls prevention to evaluate the current structure and content of hospital falls prevention programs practices and/or specific program ele- compared with evidence-based best-practice guidelines. The intent of the SAT survey ments that were associated with lower was to assist hospitals in creating action plans targeted to the best-practice elements rates of falls with injury. Assessing level that were identified as missing or in need of improvement in their current falls preven- of implementation of best practices in tion programs. falls prevention, auditing for compli- ance, and analyzing results in relation Falls Prevention Process Measures Audit Tool to rates of falls with injury can identify The Falls Prevention Process Measures Audit Tool is a point prevalence data collection significant strengths and weaknesses tool used to assess compliance with falls prevention practices most commonly included in current hospital falls prevention as part of hospital falls prevention programs. Hospitals were asked to complete quar- programs. (Pa Patient Saf Advis 2013 terly audits on the unit or units where they were piloting small tests of change as part Dec;10[4]:117-24.) of the HEN collaboration. The audit consisted of documentation review (e.g., “Was falls prevention plan documented?”) and observation of patients and the environment Scan this code (e.g., “Does patient have risk identifiers?”). with your mobile device’s QR reader to access the Authority's * The analyses upon which this publication is based were in part funded and performed under contract number HHSM-500-2012-00022C, entitled “Hospital Engagement Contractor for Part- falls prevention nership for Patients Initiative.” toolkit. Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 117 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Falls-with-Injury Rates and Falls SAT survey responses to assess any associa- between rates of falls with injury and indi- SAT Survey Responses tion between specific falls prevention best vidual falls prevention program elements. Rates of falls with injury per 1,000 patient- practices and falls-with-injury rates. days were calculated for January through First, a DerSimonian and Laird RESULTS June 2012 using falls with harm as reported random-effects meta-analysis of the logit- through PA-PSRS (i.e., any fall requiring Falls SAT Survey transformed rates per patient-day at each more than first-aid care11) and total facility facility was performed. Hospitals with more Eighty hospitals completed the falls SAT patient-days as reported to the Pennsylvania patient-days were weighted more heavily survey between July 5 and August 31, 2012. Health Care Cost Containment Council in this analysis than hospitals with fewer The majority of hospitals reported full (PHC4).12 Complete data was available for patient-days because they provide more implementation for the majority of best 75 of the 80 hospitals that responded to the statistically reliable information about the practices in falls prevention. Hospitals falls SAT survey. For 18 hospitals reporting rates of falls with injury. Subsequently, reported full implementation of an aver- zero falls with injury during this period, random-effects meta-regressions were age of 71% of best practices (range of 22% an event count of 0.01 falls was used in performed to measure the associations to 93%). Figure 1 displays the average order to permit inclusion in the meta- between rates of falls with injury and both percentage of full implementation of best analysis. Rates of falls with injury in these categories of prevention practices, as well as practices reported by hospitals, organized 75 hospitals were analyzed alongside falls by category. The range of responses in Figure 1. Percentage of Falls Prevention Best Practices with Full Implementation, by Category PERCENTAGE 100 85 83 80 79 78 74 72 71 71 70 69 65 65 60 60 57 40 44 39 20 23 0 t s n m ed nts n on n t g hm re l i c sse k i ng As pro k s g ls rs tio tion ew en m ce ris tio en atio tin Pl orin co tte ra ca e ar ai vi sm m vi or ca ica og to s a si ng Si ar re str al Be of de uc tie iron it p es du pr un Re n re ll an s s e Fa fe v m as lls m nc tiv nt nd ily ica om Fa af nt si s e l A al m Ev St e ed C th stf fa ie Pa M Po g d tin an Po ua nt al tie Ev Pa CATEGORIES OF FALLS PREVENTION PRACTICES Top quartile 50% of hospitals reported full implementation in this range MS13574 Bottom quartile Mean Note: As reported by 80 facilities in the Hospital Engagement Network. Page 118 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority all these categories reveals the variation included six best practices, four of which more than 50% of best practices to be present across all 80 HEN hospitals that the majority of hospitals reported as not fully implemented. completed the falls SAT survey. having implemented (see Table 1). The third lowest scoring category was Falls prevention practices with high levels The second lowest scoring category was sitters, or one-to-one observation. Of of full implementation. Two categories of communication. This category consisted the 48 hospitals that reported having falls prevention best practices within the of six best practices, three of which were sitter programs, only 21 reported full falls SAT survey scored highest in terms reported to have an average full imple- implementation of all six best practices of full implementation: event reporting mentation of 75% or less: (1) “When the (i.e., the sitter program includes patient and postfall assessment. Fifteen hospitals patient is transferred for testing, therapy, eligibility criteria, a process for requesting reported all best practices in the event or to another unit, is there a process in and discontinuing sitters, criteria for sit- reporting category as fully implemented. place for communicating the individual’s ter qualifications, a sitter job description The only two questions that all 80 hos- risk of falling directly to the transporter with expectations for sitter behavior and pitals scored as “Yes” were also in this and to the receiving party?”; (2) “Are indi- responsibilities, a training program for category: “Does your facility use a stan- cators promptly removed once a patient is sitters, and a pool of sitters). dardized patient safety event report for transferred or discharged?”; and (3) “Do Also of note is that only 47 hospitals internal purposes to document and report visible indicators of a patient’s risk for (59%) reported full implementation of a fall hazards, falls, and falls with harm?” falling display on the nurse call system multidisciplinary falls team with partici- and “Does it [the report] require staff to workstation?” The last question was one pants from all sectors of the facility (e.g., include the date and time of the fall?” of the lowest-scoring questions of the clinical personnel, nonclinical person- Falls prevention practices with low levels survey, with only four hospitals respond- nel, senior managers). The majority of of full implementation. Medication review ing “Yes.” As shown in Figure 1, this is hospital teams included nurses, but many was the lowest-scoring category of the falls also the only category of falls prevention were lacking pharmacists and physical SAT survey in terms of level of full imple- practices for which no hospitals reported therapists, and even more did not include mentation of best practices. This category physicians or nonclinical personnel. Table 1. Levels of Full Implementation of Falls Prevention Best Practices in the Category of Medication Review NO RESPONSE FALLS SELF-ASSESSMENT TOOL SURVEY QUESTION YES* (%) P/I† (%) NO‡ (%) (%) Do pharmacists review patient medication regimens for 26.25 15.00 56.25 2.50 potential falls risks when filling medication orders? Is there a requirement that the pharmacist inform the 10.00 6.25 81.25 2.50 prescriber and the nursing staff if prescribed medications increase the risk of falling? Does the pharmacist recommend alternative medications 12.50 12.50 72.50 2.50 to reduce the patient’s risk of falling if the prescribed medications increase the risk of falling? Does the facility’s pharmacy and therapeutics committee 13.75 12.50 71.25 2.50 periodically review formulary medications to identify those that increase falls risk and make recommendations about those medications? Are physicians encouraged to modify or eliminate 36.25 16.25 46.25 1.25 prescribed medications that increase the risk of falling? Do nurses have access to a list of medications that increase 40.00 15.00 42.50 2.50 an individual’s risk of falling that is used when assessing patients for falls risks? Note: As reported by 80 facilities in the Hospital Engagement Network. Shaded areas indicate the percentage of hospitals with no response or reporting no implementation for each best-practice question. * YES = full implementation † P/I = partial implementation/needs improvement ‡ NO = no implementation Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 119 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Falls Prevention Process Figure 2. Compliance with Use of Falls Risk Indicators in Hospitals Reporting Measures Audit Tool Full Implementation on the Falls Self-Assessment Tool Survey, July through September 2012 Sixty-three hospitals submitted baseline point prevalence audits between July 1 and September 30, 2012. A total of 1,894 % OF FALLS RISK PATIENTS patients were audited, of which 1,847 (98%) WITH INDICATOR IN PLACE had completed falls risk assessments and 100 1,292 (68%) were identified as being at risk to fall. Of the patients identified as being at risk to fall, most had a call bell within reach 80 (91%), documentation of a falls prevention plan (88%), two siderails in the up position 61 60 53 (81%), and nonskid socks or slippers (76%). 47 Falls risk identifiers, specialty equipment, and alarms were found to have lower levels 40 37 of implementation. Table 2 (available exclu- sively with this article online at http:// 20 MS13575 patientsafetyauthority.org/ADVISORIES/ AdvisoryLibrary/2013/Dec;10(4)/Pages/ home.aspx) details the percentage of 0 patients at risk to fall that were found to Wristbands Sign outside Colored socks Sign inside room room have each falls prevention practice in place. These audits were considered a baseline FALLS RISK INDICATORS assessment of compliance with falls prevention practices for the hospitals par- ticipating in the collaboration. rates ranging from 0.26 to 2.50 falls with protocols, (4) assessing risk, and (5) post- Comparison of falls SAT survey responses injury per 1,000 patient-days. fall assessment. to audit results revealed a noticeable gap Of 139 individual falls prevention best Further analyses identified 35 individual between levels of full implementation of practices included in the falls SAT survey, falls prevention practices and/or specific best practices reported on the falls SAT sur- meta-regression analyses were completed program elements that were also associ- vey and compliance with falls prevention for 136 practices. The other three were ated with lower rates of falls with injury practices observed during the audit process excluded because they were reported as (p < 0.05). See “Falls Prevention Practices (see Figure 2). For instance, in facilities fully implemented at all 75 hospitals. These and Program Elements Associated with reporting full implementation of wrist- three were assessment and documentation Lower Rates of Falls with Injury.” Also of bands used to communicate falls risk, only of a patient’s risk for falling in the patient’s note is that while use of a specific color 61% of patients at risk to fall were found to medical record on admission; use of a to communicate falls risk was found to have falls risk wristbands in place. standardized patient safety event report for be associated with lower rates of falls internal purposes to document and report with injury, no one color was found to be Falls-with-Injury Rates and Falls fall hazards, falls, and falls with harm; and associated with reductions or increases in SAT Survey Responses requiring staff to include the date and time rates of falls with harm. Seventy-five hospitals that had completed of the fall in the event report. Falls prevention practices associated the falls SAT survey had complete data Falls prevention practices associated with higher rates of falls with injury.No available to calculate rates of falls with with lower rates of falls with injury. category of falls prevention practices was injury for the period of January through Meta-regression analyses revealed 5 of 17 found to have a statistically reliable June 2012. The overall estimated rate of categories of falls prevention practices association with higher rates of falls falls with injury per 1,000 patient-days with statistically reliable associations with injury. However, hospitals report- for this group was 0.21 (95% CI: 0.17 to (p < 0.05) with lower rates of falls with ing higher levels of full implementation 0.26), with large variability among hos- injury: (1) falls prevention program design, of practices in the falls alarms category pitals. The top quartile of hospitals had (2) benchmarking, (3) policies and (continued on page 122) Page 120 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority FALLS PREVENTION PRACTICES AND PROGRAM ELEMENTS ASSOCIATED WITH LOWER RATES OF FALLS WITH INJURY Falls-with-injury rates were calculated for A process for revising assess- Staff Education the time period of January through June ment and intervention strategies — Provision of falls prevention educa- 2012 for 75 facilities that completed based on data tion to staff that the falls self-assessment tool survey in A plan to promote awareness of July and August 2012. The following occurs at orientation and peri- falls risks and prevention odically thereafter or as needed, individual falls prevention practices and specific falls prevention program elements Assessing Risk addresses the roles and respon- were found to have statistically significant — Assessment of falls risks for both sibilities of staff as part of the associations with lower rates of falls with inpatients and outpatients falls prevention education pro- injury in these 75 facilities (p < 0.05). gram, and — Requirement of routine reassess- ment of patients for their falls risks includes education for intrinsic Falls Prevention Program Design (clinical) and extrinsic (envi- — Formation of a falls prevention team — Periodic facility review of the effec- ronmental) causes of falls for that includes the following roles: tiveness of falls risk assessment tools staff members involved in direct Physicians — Use of the Hendrich II Fall Risk patient care, as appropriate for Model the staff members’ roles and Transportation managers or — Use of the General Risk Assessment responsibilities representatives for Pediatric Inpatient Falls tools Patient and Family Education — Design and implementation of a falls prevention program that does Evaluating the Environment — Provision of direct education to the following: — Requirement for patients to wear patients and their family members Defines the goals of the falls slip-proof socks or shoes regarding the causes of falls and the team and responsibilities of interventions used to prevent falls each member Medication Review Communicating Patient Risk Performs ongoing assessment of — Periodic review by the facility’s pharmacy and therapeutics commit- — Use of a specific color to identify the program’s effectiveness (at tee to identify formulary medications patients as being at risk to fall least annually) that increase falls risk and to make — Use of falls risk wristbands Develops and revises protocols recommendations about those and policies when necessary to medications Postfall Assessment and Event support the goal of preventing Reporting falls — Encouragement of physicians to modify or eliminate prescribed — Implementation of a policy on how Benchmarking medications that increase the risk to respond to patient falls — Use of an external benchmark to of falling — Educating and requiring staff to do compare facility falls rates the following: Patient Monitoring and Sitters (One- to-One Observation) Document the fall in the Policies and Protocols patient’s medical record — Development of a facility falls — Performance of hourly rounds Request a postevent systems prevention policy that includes the — Requirement for staff to stay with analysis or postfall investigation following: patients who are identified as being at risk to fall while in the bathroom — Reassessment of patients following A requirement for when an a fall for falls risk and communica- individual should be reassessed — Use of sitter programs tion of findings to staff who interact for risk — Design of sitter programs to include with the patient A description of appropriate the following: — Use of a standardized patient safety responses to falls, including pro- Criteria for sitter qualifications event report for internal purposes, tocols for postfall investigation A training program for sitters requiring staff to include extrinsic (environmental) factors A pool of sitters Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 121 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S (continued from page 120) worthy of discussion are falls prevention revealed low compliance with their use in practices associated with higher rates of patients at risk to fall. tended to have higher rates of falls with falls with injury, as well as the apparent If risk is not communicated to others injury, with a nearly statistically reliable “policy-practice gap” (i.e., interventions (e.g., during patient handoff), then the association (p = 0.056). prescribed by policy are not implemented responsibility for falls prevention cannot In analyzing individual falls prevention in practice) that was identified when be shared. Research suggests that falls practices, three practices in the categories comparing best practices reported as prevention is only effective when it is of patient monitoring, patient and family having full implementation on the falls multifactorial and provided by a multidis- education, and postfall assessment, respec- SAT survey with falls prevention practices ciplinary team.19 Reinforcing this research tively, demonstrated a statistically reliable observed during the audit process. is the finding in the current analysis of association (p < 0.05) with higher rates of an association between falls prevention falls with injury: (1) “When possible, are Medication Review teams that include physicians and trans- high-risk patients located in rooms closest The link between medications and falls portation managers or representatives to nursing stations?”; (2) “Are patients who risk has been well established, both in and lower rates of falls with injury (see are at risk of falling instructed to avoid terms of specific drug classes and poly- “Falls Prevention Practices and Program ambulating or getting out of bed without pharmacy.13-17 The impact of medication Elements Associated with Lower Rates assistance?”; and (3) “Under this policy, on falls risk may be more pronounced in of Falls with Injury”). It was reported are staff required to (and educated on how older adults but affects younger adults that less than a third of falls prevention to) complete a patient safety event report?” as well.18 teams included these roles. By failing Lastly, in analyzing specific falls preven- Best practices in medication review to communicate falls risk beyond the tion program elements, it was shown that related to falls risk have been put forth as patient and the nursing staff, the multi- hospitals that reported designing custom part of several evidence-based falls preven- disciplinary team cannot be engaged and risk assessment tools had reliably higher tion guidelines; however, the potential the effectiveness of any prevention efforts rates of falls causing harm (p < 0.05). additional cost associated with implement- may be lost. ing these practices may be one reason why Figure 3 (available exclusively with this DISCUSSION they continue to have low levels of imple- article online at http://patientsafety mentation. Further research into both the authority.org/ADVISORIES/Advisory In the Pennsylvania HEN Falls Reduction clinical effectiveness and cost effectiveness Library/2013/Dec;10(4)/Pages/home. and Prevention Collaboration to date, of these practices is warranted.17 Because aspx) displays the primary roles of falls the Authority has been able to do the this category of falls prevention practices team members as reported by HEN following: (1) identify which best practices scored lowest in terms of full implemen- facilities. in falls prevention are being included in tation, hospitals participating in the participating hospital falls prevention collaboration have been encouraged to Sitter Programs programs, (2) measure compliance with devote attention to this area, beginning The current analysis revealed an unex- implementation of best practices, and with inclusion of pharmacists on falls pected significant association between (3) identify specific falls prevention best prevention teams. use of sitter programs and lower rates practices associated with higher or lower rates of falls with injury. of falls with injury among hospitals in Communication the collaboration. While the use of sit- The three categories of falls prevention In the category of communication, the ters, or one-to-one observation, has been best practices with the lowest levels of best practices in falls prevention that were suggested in several evidence-based falls full implementation (medication review, lacking full implementation involved com- prevention guidelines,1,5,7,9 research into communication, and sitters) deserve munication of falls risk beyond the patient the clinical effectiveness of sitter programs attention. Hospitals reported an average and the nurse caring for the patient (e.g., has produced inconsistent results.20 In of 50% of best practices in these catego- falls risk is communicated in the medical addition, the use of these programs has ries as fully implemented. Of particular record, falls risk is communicated to other been questioned, especially in the current concern are the two categories found departments, falls risk indicators display economic environment, due to the high to be significantly associated with lower on the nurse call system workstation). costs associated with their maintenance. rates of falls with injury but reported to Even in hospitals reporting full imple- This may explain the low utilization of have low levels of full implementation: mentation of falls risk indicators, audits sitter programs reported by hospitals par- medication review and sitters. Also ticipating in the collaboration. Page 122 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority The significant association found between to increase in concert with increased programs is dependent on information low rates of falls with injury and the use reporting for all adverse events.21 gained from audits and information from of sitter programs, along with specific The association found between high postfall investigations. When compliance sitter program elements, suggests that rates of falls with injury and use of with falls prevention practices is low, it hospitals currently using or considering facility-designed falls risk assessment tools is the work of the multidisciplinary falls establishment of sitter programs may requires further evaluation by hospitals. prevention team to use this information benefit from ensuring adherence to best The Authority has published previously to identify barriers and design solutions. practices in administering and implement- about the importance of falls risk assess- ing the program. ment and evaluation by the hospital falls LIMITATIONS prevention team of the validity of facility- The falls SAT survey was administered Falls Prevention Practices designed risk assessment tools. If validity at hospitals in July and August 2012, Associated with Higher Rates of cannot be confirmed, the Authority sug- whereas the data used to calculate falls- Falls with Injury gests using an evidence-based falls risk with-injury rates was collected for the The practices of placing high-risk patients assessment tool with established validity.22 period of January through June 2012. in rooms closest to nursing stations and It is therefore possible that hospitals instructing patients to avoid ambulating Falls Prevention Practices Not implemented falls prevention measures in or getting out of bed without assistance Shown to Be Associated with July and August and indicated full imple- were two individual falls prevention prac- Rates of Falls with Injury mentation on the falls SAT survey even tices found to have statistically significant In the current analyses, many falls pre- though the practices were not in place associations with higher rates of falls with vention practices were found to have no when the falls with injury were occurring. injury in the current analyses. Likewise, association with rates of falls with injury. Compliance with implementation of best the category of falls alarms showed an The data only provides associations, not practices in falls prevention practices was association with higher rates of falls inferences about cause and effect. The not able to be calculated for all hospitals with injuries. sample size and methodology may be participating in the HEN falls collabora- One possible explanation for this associa- insufficient to detect differences docu- tion. Only 63 hospitals submitted audit tion may be that these practices may be mented by other studies. data. It is possible that compliance used more frequently in hospitals that with falls prevention practices may have provide care to a larger number of older Policy-Practice Gap been higher or lower across the 83 par- adults, who have a higher risk of falls Hospital falls prevention team members ticipating hospitals. In addition, while and injury (e.g., fracture risk secondary completing the falls SAT survey reported meta-regression analyses have yielded a to osteoporosis, bleeding risk due to full implementation of the majority of list of falls prevention practices that are anticoagulant use in patients with atrial best practices in falls prevention. The associated with higher or lower rates of fibrillation). Because these interventions results of the audits completed at 63 falls with injury, cause and effect cannot may be necessary in high-falls-risk popula- hospitals participating in the HEN col- be inferred. tions, evaluation of their effectiveness may laboration suggest otherwise. While it Data used in calculating falls-with-injury be better achieved through tracking falls is important to include best practices in rates is dependent on accuracy and con- and falls-with-injury rates as they relate to hospital policies and falls prevention pro- sistency in reporting falls and identifying changes in implementation of these prac- gram guidelines, assessment of the degree injury level through PA-PSRS. Hospitals tices over time. to which staff implement these practices included in this analysis have agreed to Educating and requiring staff to complete with consistency and reliability, especially a consensus definition for falls and falls patient safety event reports for falls was in patients identified as being at risk to with injury as a condition for participa- another practice found to be associated fall, is vital. tion in the HEN falls collaboration; with higher rates of falls with injury. Design of an audit process and custom- therefore, this limitation should have This may be explained by improved ization of an audit tool specific to the been minimized. The consensus defini- recognition and adherence to standard falls prevention practices of interest in tion was introduced in March 2012, definitions for reportable falls events. In a individual hospitals is suggested as part which may have affected reporting in the culture working to improve patient safety of falls prevention performance improve- baseline period. This data is also depen- and transparency, falls rates may appear ment efforts. Continual reassessment and dent on accurate and complete reporting improvement of hospital falls prevention of total facility patient-days to PHC4. Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 123 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S CONCLUSION for monitoring compliance with falls pre- Acknowledgments vention practices. Jonathan R. Treadwell, PhD, associate director, Multiple guidelines and toolkits exist to Evidence-Based Practice Center, ECRI Institute, guide and support hospitals in imple- Hospitals may consider focusing attention consulted on and contributed to statistical test- menting evidence-based best practices in on falls prevention best practices that the ing for this article. Christina Hunt, RN, MSN, MBA, HCM, senior patient safety liaison, falls prevention. Use of a self-assessment Authority has found to be associated with Pennsylvania Patient Safety Authority, HEN Falls tool, such as the falls SAT survey, can be higher or lower rates of falls with injury. Reduction and Prevention Collaboration project instrumental in identifying gaps between team leader, consulted on and contributed to The effectiveness of falls prevention pro- the review of this article. Denise M. Barger, BA, current hospital programs and evidence- cess improvement efforts may be assessed CPHRM, CPHQ, CPPS, HEM, patient safety based guidelines. Establishing a hospital through monitoring for changes in falls liaison, Delaware Valley-South, and Richard M. Kundravi, BS, patient safety liaison, Northwest falls prevention team and developing falls and falls-with-injury rates over time as Region, contributed to the design and admin- prevention policies alone is not sufficient. adjustments are made to falls prevention istration of the falls SAT survey and the Falls Use of a tool, such as the Falls Prevention practices. 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ADVISORIES/AdvisoryLibrary/2012/ Drugs and falls in older people: a Sep;9(3)/Pages/73.aspx Page 124 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 4—December 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. 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