Preventing Falls in Hospitals

Roadmap

Section	Action Steps	Tool That Supports Action	Who Should Use The Tool
Overview	Enlist support of senior leaders	Word Version [ - 30.6 KB] ;	Senior manager
Section 1	Are you ready for this change?
1.1	Assess the culture of safety in your hospital	Tool 1A, Hospital Survey on Patient Safety Culture; Word Version [ - 49.85 KB]	All interdisciplinary team members
1.2	Evaluate current organizational attention to falls	Tool 1B, Stakeholder Analysis; Word Version [ - 30.26 KB]	Implementation Team leader
1.3	Assess and develop leadership support for the fall prevention program	Tool 1C, Leadership Support Assessment; Word Version [ - 29.62 KB] Tool 1D, Business Case Form; Word Version [ - 29.16 KB]	Implementation Team leader
1.5	Identify resources that are available and resources that are needed	Tool 1E, Resource Needs Assessment; Word Version [ - 28.99 KB]	Implementation Team leader
1.7	Assess your progress on completing readiness for change activities	Tool 1F, Organizational Readiness Checklist; Word Version [ - 29.55 KB]	Implementation Team leader
Section 2	How will you manage change?
2.1	Identify your Implementation Team	Tool 2A, Interdisciplinary Team; Word Version [ - 40.94 KB]	Implementation Team leader
2.2	Assess the current status of fall prevention activities in your hospital	Tool 2B, Quality Improvement Process; Word Version [ - 30.48 KB] Tool 2C, Current Process Analysis; Word Version [ - 30.33 KB] Tool 2D, Assessing Current Fall Prevention Policies and Practices; Word Version [ - 33.9 KB]	Implementation Team leader, individuals designated by the Implementation Team leader
2.2	Determine staff knowledge about fall prevention	Tool 2E, Fall Knowledge Test; Word Version [ - 32.79 KB]	Staff nurses and nursing assistants
2.3	Set goals for improvement based on outcomes and processes	Tool 2F, Action Plan; Word Version [ - 34.66 KB]	Implementation Team leader with quality improvement/safety/risk manager
2.4	Assess your progress on completing the managing change activities	Tool 2G, Managing Change Checklist; Word Version [ - 29.25 KB]	Implementation Team leader
Section 3	Which fall prevention practices do you want to use?
3.1	Identify how fall prevention care processes connect to one another	Tool 3A, Master Clinical Pathway for Inpatient Falls; Word Version [ - 61.8 KB]	Quality improvement/safety/risk manager, staff nurses, nursing assistants
3.2	Implement universal fall precautions	Tool 3B, Scheduled Rounding Protocol; Word Version [ - 29.92 KB] Tool 3C, Tool Covering Environmental Safety at the Bedside; Word Version [ - 36.01 KB] Tool 3D, Hazard Report Form; Word Version [ - 30.13 KB] Tool 3E, Clinical Pathway for Safe Patient Handling; Word Version [ - 61.22 KB]	Unit manager, staff nurses, nursing assistants, facility engineer, hospital employee who enters patient rooms
3.3	Identify important risk factors for falls in your patients	Tool 3F, Orthostatic Vital Sign Measurement; Word Version [ - 32.37 KB] Tool 3G, STRATIFY Scale for Identifying Fall Risk Factors; Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors; Tool 3I, Medication Fall Risk Score and Evaluation Tools;	Staff nurses, pharmacist, nursing assistants
3.4	Use identified fall risk factors to implement fall prevention care planning	Tool 3J, Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method; Tool 3K, Algorithm for Mobilizing Patients; Word Version [ - 96.08 KB] Tool 3L, Patient and Family Education; Word Version [ - 29.6 KB] Tool 3M, Sample Care Plan; Word Version [ - 32.47 KB]	Educators, staff nurses, physicians, nurse practitioners, physician assistants, nursing assistants
3.5	Assess and manage patients after a fall	Tool 3N, Postfall Assessment, Clinical Review; Word Version [ - 33.64 KB] Tool 3O, Postfall Assessment for Root Cause Analysis; Word Version [ - 43.48 KB]	Staff nurses and physicians
3.8	Assess your progress on completing the best practices activities	Tool 3P, Best Practices Checklist; Word Version [ - 29.23 KB]	Implementation Team Leader
Section 4	How do you implement the fall prevention program in your organization?
4.1	Assign staff roles and responsibilities for tasks identified in set of best practices	Tool 4A, Assigning Responsibilities for Using Best Practices; Word Version [ - 29.14 KB] Tool 4B, Staff Roles; Word Version [ - 31 KB]	Implementation Team Leader, Unit manager
4.3	Assess current staff education practices and facilitate integration of new knowledge on fall prevention into existing or new practices	Tool 4C, Assessing Staff Education and Training; Word Version [ - 30.88 KB]	Implementation Team Leader
4.4	Assess your progress on implementing best practices activities	Tool 4D, Implementing Best Practices Checklist; Word Version [ - 29.22 KB]	Implementation Team Leader
Section 5	How do you measure fall rates and fall prevention practices?
5.1	Collect the right data to learn about falls, fall-related injuries, and their causes	Tool 5A, Information To Include in Incident Reports; Word Version [ - 30.61 KB]	Quality improvement/risk manager, information systems staff
5.2	Measure fall prevention practices	Tool 5B, Assessing Fall Prevention Care Processes; Word Version [ - 41.74 KB]	Unit manager and unit champions
5.3	Assess your progress on measuring progress activities	Tool 5C, Measuring Progress Checklist; Word Version [ - 29 KB]	Implementation Team Leader
Section 6	How do you sustain an effective fall prevention program?
6.3	Identify factors need to sustain your fall prevention efforts	Tool 6A, Sustainability Tool; Word Version [ - 32.85 KB]	Implementation Team Leader

Page last reviewed January 2013
Page originally created January 2013

Internet Citation: Roadmap. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtkmap.html