AuthorAffiliations:Assistant Professor (DrZhao), School ofNurs-ing, Boise State University, Idaho; Associate Dean, and Research andAssociate Professor (DrBott), School ofNursing; andAssociate Profes-sor (Dr He), Department of Biostatistics, University of Kansas, KansasCity; Assistant Professor (Dr Kim), College of Nursing, Yonsei Uni-versity, Seoul, South Korea; and Assistant Professor (Dr Park) andResearch Professor (Dr Dunton), School of Nursing, University ofKansas, Kansas City.
The authors declare no conflicts of interest.Correspondence: Dr Zhao, School of Nursing, Boise State
University, 1910 University Dr, Mail Stop 1840, Boise, ID 83725([email protected]).
DOI: 10.1097/NNA.0000000000000715
86
Copyright © 2019 Wolters Kluw
Dow
nloaded from http://journals.lw
w.com
/jonajournal by BhD
Mf5eP
HK
av1zEoum
1tQfN
4a+kJLhE
ZgbsIH
o4XM
i0hCyw
CX
1AW
nYQ
p/IlQrH
D3i3D
0OdR
yi7TvS
Fl4C
f3VC
1y0abggQZ
Xdtw
nfKZ
BY
tws=
on 05/09/2023
JONAVolume 49, Number 2, pp 86-92Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N
Evidence on Fall and Injurious FallPrevention Interventions in AcuteCare Hospitals
Yunchuan (Lucy) Zhao, PhD, RNMarjorie Bott, PhD, RNJianghua He, PhD
er
Heejung Kim, PhD, RNShin Hye Park, PhD, RNNancy Dunton, PhD, RN
Falls and injurious falls are a major safety concern forpatient care in acute care hospitals. Inpatient falls andinjurious falls can cause extra financial burden to pa-tients, families, and healthcare facilities. This articleprovides clinical implications and recommendationsfor adult inpatient fall and injurious fall preventionthrough a brief review of factors associated with fallsand injurious falls and current fall prevention prac-tices in acute care hospitals.
The problem of adult inpatient falls and injurious fallsin acute care hospitals has been a serious safety con-cern for patient care. In acute care hospitals, inpatientfalls are the most common incidents reported bynurses and other healthcare team members.1-4 In theUnited States, the average fall rate is about 3 to 5 fallsper 1000 patient days with approximately 1 millionannual falls in hospitals. Falls during hospitalizationcan have numerous negative consequences to patientsand families, including fear of falling, depression, in-juries, reduced mobility and functional ability, anddecreased independent living and quality of life.4,5
Injuries resulting from inpatient falls can causeextra financial burden and decreased revenue tohealthcare facilities. On average, injurious falls lead
to an increased length of hospital stay by 6 to 12 daysand an additional cost of $13,316.6 Because the Cen-ters forMedicare andMedicaid Services no longer re-imburses hospitals for treatment of preventable injuries,including fall-related injuries,7 not only will hospitalspay the extra cost for these fall-related injuries, hospi-tals will sustain revenue losses.
Falls and falls-related injuries are listed as one ofthe nursing-sensitive care outcome measures by theNational Quality Forum.8 It is essential to prevent in-patient falls and related injuries so as to deliver high-quality care. To deliver high-quality care, nurse leadersin acute care hospitals need to have: a) the knowledgeof specific risk factors associated with inpatient fallsand injurious falls; b) common fall prevention inter-ventions; and c) potential strategies for effective falland injurious fall prevention in acute care hospitals.The information presented hereinafter will assist nurseleaders to develop organizational policies and pro-grams that aim at effective fall and injurious fall pre-vention targeting adult inpatients.
Factors Associated With Falls andInjurious FallsEvidence shows that inpatient falls and injurious fallsare a complicated phenomenon that involves multiplefactors, including intrinsic and extrinsic factors.4,9,10
Intrinsic factors are patient-specific factors, and ex-trinsic factors include hospital organizational factors,nurse staffing, and nursing process factors.
Intrinsic FactorsEvidence demonstrates the association between ad-vanced age, and inpatient falls and injurious falls.11-15
Among inpatient falls, about 50% occur in patients
JONA � Vol. 49, No. 2 � February 2019
Health, Inc. All rights reserved.
Dow
nloaded from http://journals.lw
w.com
/jonajournal by BhD
Mf5eP
HK
av1zEoum
1tQfN
4a+kJLhE
ZgbsIH
o4XM
i0hCyw
CX
1AW
nYQ
p/IlQrH
D3i3D
0OdR
yi7TvS
Fl4C
f3VC
1y0abggQZ
Xdtw
nfKZ
BY
tws=
on 05/09/2023
60years andolder,whereas patients older than80yearsare significantly at the highest risk for falls and injuriousfalls.11,14,15 Interestingly, the evidence on the relation-ship between gender and falls is inclusive because bothgenders are identified as a risk factor for falls or inju-rious falls in previous studies11-13,15,16 or no associa-tion is identified at all.10 Certain medical conditionssuch as cognitive impairment, impaired mobility, hy-pertension, osteoporosis, and stroke also are risk fac-tors for falls or injurious falls.4,9,11,16 However, beingon anticoagulation therapy does not place patients atan increased risk for bleeding injury after a fall.17,18
Extrinsic FactorsHospital and unit organizational characteristics alsoare found to be associated with patient falls and inju-rious falls. Teaching and Magnet® hospitals in gen-eral have less falls and injurious falls.10,19,20 In thesehospitals, nurses often report higher perceptions ofthe quality of work, work environment, nursing lead-ership, and job satisfaction, which all contribute tobetter quality of care and patient outcomes.20,21 Ac-cording to recent studies, mixed results are reportedwhen analyzed by unit type—surgical units have anincreasing rate of falls or injurious falls10,22—althoughprevious studies suggested that medical units had thehighest rates of falls and injurious falls.19,23
Several nursing process factors significantly con-tributing to falls and injurious falls require attentionfrom nurse administrators and managers. Fall riskassessment and fall prevention protocols are 2 impor-tant nursing process factors in preventing falls andinjurious falls.12,19 Patients who are identified at riskfor falls through fall risk assessment are 21% less likelyto have injurious falls.10 In clinical practice, nursesoften initiate a fall prevention protocol to patientsidentified at fall risk. With a fall prevention protocolimplemented, falls are more likely to be assisted by em-ployees, which can reduce fall-related injuries.10,19
Studies indicate that falls without employee assistanceare 50%more likely to result in injuries than falls withemployee assistance.10-13,19 Because about 12% to69% of falls are related to urinary and bowel elimina-tion needs, providing assistance when patients need togo to the bathroom is essential in preventing falls.9
Fall Prevention Interventions
Existing Fall Prevention InterventionsIn the last decades, many fall prevention interventionshave been developed and implemented in acute carehospitals. Based on the characteristics of interventioncomponents, fall prevention interventions can be cate-gorized into (a) environmental, (b) educational, (c) com-municational, or (d) nursing process interventions.2,4,24
JONA � Vol. 49, No. 2 � February 2019
Copyright © 2019 Wolters Kluwer H
Environmental InterventionsEnvironmental interventions may focus on the effortsto create a clutter-free, safe environment.2,4 Specifi-cally, environmental interventions include modifyingthe hospital environment with vinyl flooring2,25 andensuring the patient bed is in low position.24 Modify-ing the hospital environment with vinyl flooring helpsprevent falls because hospital units with carpeted floorshave increased fall rates compared with units with vinylfloors.2,25 However, lowering hospital beds shows nosignificant effect in preventing inpatient falls.4,26
Educational InterventionsStaff and patient education on fall prevention are 2major components of educational interventions.2,24
Staff education is used to raise staff awareness of fallprevention or provide training for fall risk assessmenttools.2,4 Patient education programs aim to improvepatient knowledge of: a) fall prevalence and conse-quences; b) causes of falls; c) hospital fall preventionstrategies; and d) self-reflection of individual risk anda goal-setting review.27,28 Evidence shows that staffor patient education as a single intervention strategyhas been effective in preventing inpatient falls andinjurious falls.2,4 With education, staff and patientsoften have improved knowledge on fall risks and pos-itive attitudes on fall prevention. Education can alsohelp staff implement appropriate fall preventionsand promote active patient engagement in fallprevention.4,26,28
Communicational InterventionsCommunicational interventions use visual alert signs,verbal communications, or electronic alarm systemsto assist fall prevention. Visual signs including yellowwristband and fall risk signs alert staff to the patientsat a high risk for falling.2,4,24 Electronic bed or chairalarms alert staff to the movement of high–fall riskpatients so that the staff can provide assistance or sup-port.4,24 Awareness posters (ie, call don't fall, keepcalm) remind the patient to call staff for help to pre-vent falls.2,24 These communicational interventionsoften are used in combination with other fall preven-tion strategies.4,24,29
Nursing Process InterventionsNursing process interventions aiming to prevent fallsinclude fall risk assessment, fall protocol implementa-tion, and postfall review/evaluations.4,24,29 Fall riskassessment is the most common nursing process inter-vention.24,29 Based on fall risk assessment, a fall pre-vention protocol often is implemented on patientsidentified at a high risk for falls. A fall prevention pro-tocol usually consists of patient education; visual alertsigns; electronic alert systems; care, safety, and toiletingrounds; and ambulation assistance.4,24 Care, safety, andtoileting rounds, often referred to as hourly rounding,
87
ealth, Inc. All rights reserved.
Dow
nloaded from http://journals.lw
w.com
/jonajournal by BhD
Mf5eP
HK
av1zEoum
1tQfN
4a+kJLhE
ZgbsIH
o4XM
i0hCyw
CX
1AW
nYQ
p/IlQrH
D3i3D
0OdR
yi7TvS
Fl4C
f3VC
1y0abggQZ
Xdtw
nfKZ
BY
tws=
on 05/09/2023
is a common practice in acute care hospitals. Duringthese rounds, nursing staff purposely check on the pa-tients at regular intervals to ensure patients are receiv-ing the care and assistance as needed.30 As a singleintervention, hourly rounding has proved to be an ef-fective strategy in preventing falls and improving pa-tient satisfaction of nursing care.25,30 Postfall reviewor evaluations that have shown some effectiveness inpreventing future or recurrent inpatient falls31 areused in many hospitals.4,24,29
Issues With Existing Fall Prevention InterventionsFalls and injurious falls are still prevalent in many UShospitals.23 Yet, the effectiveness of existing fall pre-vention interventions varies.2,4,24 In the literature, sev-eral major issues that affect the success of hospital fallprevention interventions are identified including fallrisk assessment, fall prevention components, and inter-vention implementation and adherence.4,24,29
Fall Risk AssessmentMost fall prevention intervention approaches includefall risk assessment.24,29 Fall risk assessment often isconducted with an assessment tool or nursing judg-ment. However, a recent systematic review of hospitalfall prevention programs revealed that more than halfof the studies used an assessment tool that did nothave reported validity and reliability testing.24 Be-cause fall risk assessment is an important approachfor fall prevention, using an assessment tool that doesnot have reported validity and reliability testing maythreaten the accuracy of the assessment. As a result,fall assessment may not correctly identify patients atrisk for falls.32
Fall Prevention ComponentsMost fall prevention interventions consist of multiplecommon components including fall risk assessment,patient and staff education, visual alert signs, andhourly rounding.4,24,29 However, an optimal bundleof intervention components cannot be identified be-cause there has not been strong evidence on whatcomponents are most important for successful fallinterventions.29
Intervention Implementation and AdherenceThe implementation and adherence of fall preventioninterventions has been a determining factor in suc-cessful fall prevention programs. Without appropri-ate implementation and adherence, fall interventionsmay not be effective in preventing falls and injuriousfalls.24,29 Major challenges in the implementationand adherence of fall prevention interventions includepoor organizational prioritization of fall prevention,complacent staff attitude toward fall prevention,and poor compliance with existing fall preventionprotocols.33-36
88
Copyright © 2019 Wolters Kluwer
Clinical Implications and RecommendationsExisting evidence suggests that inpatient falls andinjurious falls can be complicated. Therefore, preventingfalls and injurious falls can be challenging. Nurse ad-ministrators and nurse managers need to considermultilevel factors associated with inpatient falls andinjurious falls. Based on the evidence on the effective-ness of and issues in the existing fall prevention inter-ventions, the following strategies should be used infall and injurious fall prevention interventions toimprove the success of fall prevention interventions.Table 1 lists examples of effective multicomponentfall programs and implementation strategies.
Provide Strong Leadership SupportLeadership support has been identified as an essentialfactor for successful fall and injurious falls preventionin acute care hospitals in several systematic reviews ofinpatient fall prevention programs.24,29 With strongleadership support, patient safety and fall preventionare established as organizational priorities and a cul-ture of patient safety is emphasized and promotedthroughout the hospitals, which facilitates fall preven-tion interventions.24,29,35,36
Develop Appropriate Prevention ProgramsEvidence suggests individualized fall prevention inter-ventions are important in preventing falls and injuri-ous falls. Given the known risk factors for inpatientfalls and injurious falls and the positive impact of fallassessment on fall prevention,12,19 all fall preventionprograms should begin with an appropriate fall riskassessment. Commonly used adult fall assessment toolsincludeMorse Fall Scale (MFS), St. Thomas Risk Assess-ment Tool in Falling Elderly Inpatients (STRATIFY),Hendrich II Fall Risk Model (HIIFRM), and JohnsHopkins Fall Risk Assessment Tool (JHFRAT). Amongthese tools, MFS and HIFRM have positive predica-tive validity in identifying patients at a high risk for falls,whereas STRATIFY and JHFRAT are better in differ-entiating patients at low fall risks from those at highrisks24,43,44 (Table 2).
For high–fall risk patients, appropriate fall pre-vention intervention should be developed based onthe results of fall assessment. Multicomponent inter-ventions with different combinations of fall preven-tion strategies have been effective in hospitals withdifferent sizes, locations, and teaching status.24,27,29,36-42
Although the components of these fall intervention pro-gram vary, the success of these multicomponent pro-grams suggests that an effective fall prevention programshould include the following components: fall riskassessment, fall alert signs, staff education, patienteducation, movement alarms, and hourly roundingespecially assessing patients' need for toileting.29,36-42
JONA � Vol. 49, No. 2 � February 2019
Health, Inc. All rights reserved.
Table 1. Fall Intervention Components and Implementation Strategies
Intervention Components Implementation Strategies Outcomes Setting
Ang et al,27
2011• Fall risk assessment • Staff education Significantly decreased falls
compared with the controlgroup
Medical units/adultpatients, geriatricpatients
• Staff education• Patient education• Environment modification• Fall alert signs• Toileting schedules• Medication review• Low-low beds
Barker et al,37
2009• Fall risk assessment • Staff education Significantly decreased
injurious falls after theintervention
Medical units, surgicalunits/adult patients• Staff education
• Fall alert signs• Assistance with toileting• Toileting schedules• Assistance with ambulating• Movement alarms• Low-low beds
Dykes et al,38
2010• Fall risk assessment • Continuous quality
improvementSignificantly decreased falls
compared with the controlgroup
Medical units/adultpatients, geriatricpatients
• Patient education• Fall alert signs• Assistance with toileting• Assistance with ambulating• Purposeful rounding
France et al,39
2017• Fall risk assessment • Leadership support Significantly decreased falls
after the interventionMedical, surgical,
medical-surgicalunits/adult patients
• Staff education • Multidisciplinary team• Patient education• Fall alert signs
• Ongoing audit
• Environment modification• Hourly rounding• Movement alarms
Hunderfundet al,40
2011
• Fall risk assessment • Staff education Significantly decreased fallscompared with the controlgroup
Medical units, neurologyunits/adult patients• Fall alert signs
• Patient education• Staff education• Assistance with ambulating• Care rounding• Movement alarms• Low-low beds
Krauss et al,41
2008• Fall risk assessment • Staff education Significantly decreased falls
after the interventionMedical units/adult
patients• Environment modification• Fall alert signs• Staff education• Patient education• Hourly rounding• Movement alarms• Medication review• Low-low beds
Trepanier andHilsenbeck,42
2014
• Fall risk assessment • Staff education Significantly decreasedinjurious falls after theintervention
Medical units, surgicalunits, medical-surgical units/adultpatients
• Hourly rounding • Implementation audit• Staff education • Leadership support• Patient education• Continuous observation for
high–fall risk patients• Mediation review• Individualized care plan• Postfall assessment
Weinberget al,36
2011
• Fall risk assessment • Staff education Significantly decreasedfalls and injurious fallsafter the intervention
Medical, surgical,rehabilitation units/adult patients
• Fall alert signs • Leadership support• Patient education • Multidisciplinary fall
committee• Staff education• Hourly rounding• Movement alarms• Postfall review
JONA � Vol. 49, No. 2 � February 2019 89
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Dow
nloaded from http://journals.lw
w.com
/jonajournal by BhD
Mf5eP
HK
av1zEoum
1tQfN
4a+kJLhE
ZgbsIH
o4XM
i0hCyw
CX
1AW
nYQ
p/IlQrH
D3i3D
0OdR
yi7TvS
Fl4C
f3VC
1y0abggQZ
Xdtw
nfKZ
BY
tws=
on 05/09/2023
Table 2. Fall Risk Assessment Tools
Tool Assessment Items Risk Score Validity/Reliability Setting/Population
MFS24 • History of falling <25, low risk Sensitivity, 0.72-0.96 Medical, surgical,medical-surgical units/adult patients
• Secondary diagnosis 25-45, moderate risk Specificity, 0.51-0.83• Ambulatory aid >45, high risk• Intravenous therapy• Gait• Mental status
STRATIFY Scale43 • History of falling 0, low risk Sensitivity, 0.54-0.69 Medical, surgical, geriatric,oncology units/geriatricpatients
• Patient agitation 1, moderate risk Specificity, 0.67-0.73• Visual impairment >=2, high risk• Frequent toileting• Transfer and mobility abilities
HIIFRM43• Confusion/disorientation/
impulsivity<3, low risk Sensitivity, 0.84-0.97 Medical units, geriatric
hospital/geriatricpatients• Symptomatic depression
3-5, moderate risk Specificity, 0.33-0.41
• Altered elimination>5, high risk
• Vertigo/dizziness• Male gender• Use of antiepileptics• Use of benzodiazepines• Get-Up-and-Go test
JHFRAT44• Age <6, low risk Sensitivity, 0.26 Medical units/adult
patients• Fall history 6-13, moderate risk Specificity, 0.89• Elimination >13, high risk• Medications• Patient care equipment• Mobility• Cognition
Sensitivity indicates the proportion of fallers correctly classified as at high fall risk; specificity indicates the proportion of nonfallers correctly classified asat low fall risk.
Dow
nloaded from http://journals.lw
w.com
/jonajournal by BhD
Mf5eP
HK
av1zEoum
1tQfN
4a+kJLhE
ZgbsIH
o4XM
i0hCyw
CX
1AW
nYQ
p/IlQrH
D3i3D
0OdR
yi7TvS
Fl4C
f3VC
1y0abggQZ
Xdtw
nfKZ
BY
tws=
on 05/09/2023
In addition to these interventions, an individual-ized fall prevention plan needs to be developed byconsidering different patient populations in varioushospital units. For example, research suggests thatsurgical units have more injurious falls among inpa-tient falls compared with medical, medical-surgical,and step-down units.10 In acute care hospitals, manysurgical units have implemented the Enhanced RecoveryAfter Surgery programs, in which early postoperativemobilization is promoted.45,46With early postoperativemobilization, patients can develop orthostatic intoler-ance that further causes falls and injurious falls.47,48
The administration of analgesic medications to post-operative patients also increases these patients' riskfor falls because of the side effects of analgesics.47-50
Fall prevention interventions on surgical units needto be focused on providing ambulatory assistance byemployees given the association between early post-operative mobilization and falls. Research shows thatfalls with employee assistance result in significantlyless injurious falls compared with falls without employeeassistance.10-13,19 Therefore, providing employee as-sistance to patients as needed is a critical method forinjurious fall prevention.
For older adult patients, medication review is anessential component of fall interventions. Hospitalizedolder adult patients often have chronic diseases with
90
Copyright © 2019 Wolters Kluwer
multiple medications. Polypharmacy is independentlyassociated with adverse outcomes including falls. Cer-tain medications commonly prescribed in older adultpatients, including antihypertensive, antiepileptics, psy-chotropics, and opioid analgesic drugs, contribute tofalls because of the side effects of sedation, orthostatichypotension, and confusion.47-50 Nurses need to care-fully reviewmedications in older adult patients and takeappropriate actions to prevent falls.
Enhance Intervention Implementation andAdherenceTo ensure successful fall prevention, nurse leadersmust ensure successful fall prevention interventionimplementation and adherence. Given the issues ofcomplacent attitude and poor compliance with existingfall prevention protocols in intervention implementa-tion and adherence,33-36 staff education should be en-hanced and staff should be engaged in fall preventionto change staff attitudes and improve intervention im-plementation and adherence. Staff education on theimportance of patient safety and fall prevention hasbeen an effective strategy in changing staff's complacentattitude toward fall prevention.33,34 Staff involvementis a key factor in successful fall prevention interven-tions. In many successful fall prevention programs,frontline nursing staff are engaged in the interventiondesign and implementation as either members of the
JONA � Vol. 49, No. 2 � February 2019
Health, Inc. All rights reserved.
Dow
nloaded from http://journals.lw
w.com
/jonajournal by BhD
Mf5eP
HK
av1zEoum
1tQfN
4a+kJLhE
ZgbsIH
o4XM
i0hCyw
CX
1AW
nYQ
p/IlQrH
D3i3D
0OdR
yi7TvS
Fl4C
f3VC
1y0abggQZ
Xdtw
nfKZ
BY
tws=
on 05/09/2023
multidisciplinary fall prevention team or the unitchampions for fall prevention enhancement.33,34,36
The involvement of frontline nursing staff has im-proved the compliance with fall prevention protocols,enhanced intervention implementation, and increasedintervention adherence.33,34,36Nursing leadership shouldengage frontline nursing staff in fall prevention inter-vention development and implementation to ensurebuy-in from staff and successful adoption of the pre-vention strategies.
In the implementation of fall prevention interven-tions, nurse staffing is an important factor that nurs-ing leadership needs to consider. Evidence shows arelationship between nurse staffing (ie, total nursinghours per patient day [TNHPPD], RN hours per pa-tient day [RNHPPD], and proportion of RN hours)and inpatient falls and/or injurious falls.10,18,20,22 Pre-vious studies suggest negative associations between in-patient fall rates with lower TNHPPD and proportionof RN hours.20,22 The relationship between injuriousfall rates and TNHPPD, RNHPPD, and proportionof RN hours is complicated. The results of a recentstudy on injurious fall rates among inpatients whofell showed a nonlinear relationship between injuri-ous fall rates and RNHPPD. The optimal RNHPPDapproximately reaches 5 in relation to injurious falls:the higher the RNHPPD before it reaches 5, the lowerinjurious falls; after RNHPPD reaches 5, the relationship
JONA � Vol. 49, No. 2 � February 2019
Copyright © 2019 Wolters Kluwer H
becomes positive.10 Given the nonlinear associationbetween injurious fall rates and nurse staffing, nurseleaders need to ensure proper and adequate staffingin patient care. Without adequate staffing, it is chal-lenging for nursing staff to implement appropriatefall prevention interventions to prevent falls and in-jurious falls.
ConclusionInpatient falls and injurious falls in acute care hospi-tals are a complicated phenomenon that makes falland injurious fall prevention a challenge for nurse ad-ministrators and managers. To ensure prevention inter-ventions for falls and, more importantly, injurious fallsare successful, multicomponent prevention and validassessment under strong leadership should be imple-mented to focus on safety and quality nursing care.In addition, involving frontline staff in the develop-ment and implementation of fall prevention interven-tions and fall risk assessment is important for buy-inand successful adherence. Other strategies for suc-cessful fall prevention intervention adherence are staffeducation and appropriate nurse staffing. In addition,nurse leaders need to develop fall prevention interven-tions based on effective intervention strategies withthe consideration of known factors associated withinpatient falls and injurious falls.
References
1. Anderson O, Boshier PR, Hanna GB. Interventions designed toprevent healthcare bed-related injuries in patients. CochraneDatabase Syst Rev. 2012;1:CD008931. doi:10.1002/14651858.CD008931.pub3.
2. Cameron ID, Gillespie LD, Robertson MC, et al. Interventionsfor preventing falls in older people in care facilities and hospi-tals. Cochrane Database Syst Rev. 2012;12:CD005465. doi:10.1002/14651858.CD005465.pub2.
3. National Patient Safety Agency. Slips, trips and falls in hospital.http://www.nrls.npsa.nhs.uk. Accessed October 5, 2017.
4. Oliver D, Healey F, Haines TP. Preventing falls and fall-relatedinjuries in hospitals. Clin Geriatr Med. 2010;26(4):645-692.doi:10.1016/j.cger.2010.06.005.
5. ChungMC,McKee KJ, AustinC, et al. Posttraumatic stress dis-order in older people after a fall. Int J Geriatr Psychiatry. 2009;24(9):955-964. doi:10.1002/gps.
6. WongCA,RecktenwaldAJ, JonesML,WatermanBM,BolliniML,Dunagan WC. The cost of serious fall-related injuries at threeMidwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37(2):81-87.
7. Centers forMedicare&Medicaid Services.Medicare program:changes to the hospital inpatient prospective payment systemsand fiscal year 2009 rates; payments for graduate medical edu-cation in certain emergency situations; changes to disclosure ofphysician ownership in hospitals and physician self-referralrules; updates to the long-term care prospective payment sys-tem; updates to certain IPPS-excluded hospitals; and collection
of information regarding financial relationships between hospi-tals. Final rules. Fed Regist. 2008;73(161):48433-49084.
8. National Quality Forum. National voluntary consensus stan-dards for nursing-sensitive care: an initial performance measureset. https://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx.Accessed July 7, 2018.
9. Zhao YL, Kim H. Older adult inpatient falls in acute carehospitals: intrinsic, extrinsic, and environmental factors.J Gerontol Nurs. 2015;41(7):29-43. doi:10.3928/00989143-20150616-05.
10. ZhaoYL, BottM,He J, KimH, Park SH,DuntonN.Multilevelfactors associated with injurious falls in acute care hospitals.J Nurs Care Qual. 2017;33(1):20-28. doi:10.1097/NCQ.0000000000000253.
11. Brand CA, Sundararajan V. A 10-year cohort study of the bur-den and risk of in-hospital falls and fractures using routinelycollected hospital data. Qual Saf Health Care. 2010;19(6):e51. doi:10.1136/qshc.2009.038273.
12. Chari S, McRae P, Varghese P, Ferrar K, Haines TP. Predictorsof fracture from falls reported in hospital and residential carefacilities: a cross-sectional study. BMJ. 2013;3(8):e002948.doi:10.1136/bmjopen-2013-002948.
13. Krauss M, Nguyen S, Dunagan C, et al. Circumstances of pa-tient falls and injuries in 9 hospitals in aMidwestern healthcaresystem. Infect Control Hosp Epidemiol. 2007;28(3):544-550.
91
ealth, Inc. All rights reserved.
Dow
nloaded from http://journals.lw
w.com
/jonajournal by BhD
Mf5eP
HK
av1zEoum
1tQfN
4a+kJLhE
ZgbsIH
o4XM
i0hCyw
CX
1AW
nYQ
p/IlQrH
D3i3D
0OdR
yi7TvS
Fl4C
f3VC
1y0abggQZ
Xdtw
nfKZ
BY
tws=
on 05/09/2023
14. Mion LC, Chandler AM, Waters TM, et al. Is it possible toidentify risks for injurious falls in hospitalized patients?Jt Comm J Qual Patient Saf. 2012;38(9):408-413.
15. Williams T, Szekendi M, Thomas S. An analysis of patientfalls and fall prevention programs across academic medicalcenters. J Nurs Care Qual. 2014;29(1):19-29. doi:10.1097/NCQ. 0b013e3182a0cd19.
16. Neumann L, Hoffmann VS, Golgert S, Hasford J, von Renteln-Kruse W. In-hospital fall-risk screening in 4,735 geriatric pa-tients from the LUCAS project. J Nutr Health Aging. 2013;17(3):264-269. doi:10.1007/s12603-012-0390-8.
17. Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds inpatients on oral anticoagulation therapy. Am J Med. 2012;125(8):773-778. doi:10.1016/j.jvs.2012.11.053.
18. Inui TS, Parina R, Chang DC, Inui T, Coimbra R.Mortality af-ter ground-level fall in the elderly patient taking oral anticoag-ulation for atrial fibrillation/flutter: a long-term analysis of riskversus benefit. J Trauma Acute Care Surg. 2014;76(3):642-650.doi:10.1097/TA.0000000000000138.
19. StaggsVS,MionLC, ShorrRI. Assisted and unassisted falls: differ-ent events, different outcomes, different implications for quality ofhospital care. Jt Comm J Qual Patient Saf. 2014;40(8):358-364.
20. Lake ET, Shang J, Klaus S, Dunton NE. Patient falls: associa-tion with hospital Magnet status and nursing unit staffing.Res Nurs Health. 2010;33:413-425. doi:10.1002/nur.20399.
21. Aiken LH, Sermeus W, Van den Heede M, et al. Patient safety,satisfaction, and quality of hospital care: cross sectional surveysof nurses and patients in 12 countries in Europe and the UnitedStates. BMJ. 2012;344:e1717. doi:10.1136/bmj.e1717.
22. He J, Dunton N, Staggs V. Unit-level time trends in inpatientfall rates of US hospitals.Med Care. 2012;50(9):800-807.
23. Bouldin EL, Andersen EM, Dunton NE, et al. Falls amongadult patients hospitalized in the United States: prevalenceand trends. J Patient Saf. 2013;9(1):13-17. doi:10.1097/PTS.0b013e3182699b64.
24. Hempel S, Newberry S,Wang Z, et al. Hospital fall prevention:a systematic review of implementation, components, adher-ence, and effectiveness. J Am Geriatr Soc. 2013;61(4):483-494.doi:10.1111/jgs.12169.
25. Donald IP, Pitt K, Armstrong E, Shuttleworth H. Preventingfalls on an elderly care rehabilitation ward.Clin Rehabil. 2000;14(2):178-185.
26. Haines T, Bell R, Varghese P. Pragmatic, cluster randomisedtrial of a policy to introduce low-low beds to hospital wardsfor the prevention of falls and fall injuries. J Am Geriatr Soc.2010;58(3):435-441.
27. Ang E,Mordiffi SZ,WongHB. Evaluating the use of a targetedmultiple intervention strategy in reducing patient falls in anacute care hospital: a randomized controlled trial. J Adv Nurs.2011;67(9):1984-1992. doi:10.1111/j.1365-2648.2011.05646.x.
28. Haines TP, Hill AM, Hill KD, et al. Patient education to pre-vent falls among older hospital inpatients: a randomized con-trolled trial. Arch Intern Med. 2011;171(6):516-524. doi:10.1001/archinternmed.2010.444.
29. Miake-Lye IM, Hempel S, GanzDA, Shekelle PG. Inpatient fallprevention programs as a patient safety strategy: a systematicreview. Ann Intern Med. 2013;158:390-396. doi:10.7326/0003-4819-158-5-201303051-00005.
30. MitchellMD, Lavenberg JG, Trotta RL, Umscheid CA. Hourlyrounding to improve nursing responsiveness: a systematicreview. J Nurs Adm. 2014;44(9):462-472. doi:10.1097/NNA. 0000000000000101.
31. Gray-Miceli D, Ratcliffe SJ, Johnson J. Use of a postfall assess-ment tool to prevent falls.West JNursRes. 2010;32(7):932-948.doi:10.1177/0193945910370697.
92
Copyright © 2019 Wolters Kluwer
32. Waltz CF, Strickland OL, Lenz ER. Measurement in NursingandHealthResearch. 4th ed.NewYork,NY: Springer PublishingCompany; 2010.
33. Capan K, Lynch B. A hospital fall assessment and interventionproject. J Clin Outcomes Manag. 2007;14:155-160.
34. Gutierrez F, Smith K. Reducing falls in a definitive observationunit: an evidence-based practice institute consortium project.Crit Care Nurse. 2008;31:127-139.
35. Kolin MM, Minnier T, Hale KM, Martin SC, Thompson LE.Fall initiatives: redesigning best practice. J Nurs Adm. 2010;40:384-391.
36. Weinberg J, Proske D, Szerszen A, et al. An inpatient fall pre-vention initiative in a tertiary care hospital. Jt Comm J QualPatient Saf. 2011;37:317-325.
37. Barker A, Kamar J, Morton A, Berlowitz D. Bridging the gapbetween research and practice: review of a targeted hospital in-patient fall prevention programme. Qual Saf Health Care.2009;18(6):467-472. doi:10.1136/qshc.2007.025676.
38. Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acutecare hospitals: a randomized trial. JAMA. 2010;304(17):1912-1918. doi:10.1001/jama.2010.1567.
39. France D, Slayton J,Moore S, et al. A multicomponent fall pre-vention strategy reduces falls at an academic medical center.Jt Comm J Qual Patient Saf. 2017;43(9):460-470. doi:10.1016/j.jcjq.2017.04.006.
40. Hunderfund AN, Sweeney CM, Mandrekar JN, Johnson LM,Britton JW.Effect of amultidisciplinary fall risk assessment on fallsamong neurology inpatients.Mayo Clin Proc. 2011;86(1):19-24.
41. KraussMJ, TutlamN, Costantinou E, et al. Intervention to pre-vent falls on the medical service in a teaching hospital. InfectControl Hosp Epidemiol. 2008;29(6):539-545.
42. Trepanier S, Hilsenbeck J. A hospital system approach at decreas-ing falls with injuries and cost.Nurs Econ. 2014;32(3):135-141.
43. MatareseM, IvzikuD, Bartolozzi F, PireddaM,DeMarinisM.Systematic review of fall risk screening tools for older patientsin acute hospitals. J Adv Nurs. 2015;71(6):1198-1209. doi:10.1111/jan.12542.
44. Klinkenberg W, Potter P. Validity of the Johns Hopkins FallRisk Assessment Tool for predicting falls on inpatient medicineservices. J Nurs Care Qual. 2017;32(2):108-113. doi:10.1097/NCQ.0000000000000210.
45. Feldman LS, Lee L, Fiore J Jr. What outcomes are important inthe assessment of Enhanced Recovery after Surgery (ERAS)pathways? Can J Anaesth. 2015;62(2):120-130. doi:10.1007/s12630-014-0263-1.
46. Watson DS. The benefits of enhanced recovery pathways inperioperative care. AORN J. 2015;102(5):464-467. doi:10.1016/j.aorn.2015.09.010.
47. Bundgaard-Nielsen M, Jørgensen CC, Jørgensen TB, et al. Or-thostatic intolerance and the cardiovascular response to earlypostoperative mobilization. Br J Anaesth. 2009;102(6):756-762.doi:10.1093/bja/aep083.
48. Jans Ø, Bundgaard-Nielsen M, Solgaard S, Johansson PI,Kehlet H. Orthostatic intolerance during early mobilization afterfast-track hip arthroplasty. Br J Anaesth. 2013;108(3):436-443.doi:10.1093/bja/aer403.
49. Marvin V, Ward E, Poots AJ, et al. Deprescribing medicines inthe acute setting to reduce the risk of falls. Eur J Hosp PharmSci Pract. 2017;24(1):10-15. http://dx.doi.org/10.1136/ejhpharm-2016-001003.
50. Costa-Dias MJ, Oliveira AS, Martins T, et al. Medication fallrisk in old hospitalized patients: a retrospective study.Nurse EducToday. 2014;34(2):171-176. doi:10.1016/j.nedt.2013.05.016.
JONA � Vol. 49, No. 2 � February 2019
Health, Inc. All rights reserved.