Nursing Leadership, Nursing Research (Annotated bibliography), Pathophysiology and Advanced Pathophysiology (Due 20 hours)
Edero2103
Falls6.pdf
Implementation of a Fall Prevention Toolkit on a Medical Surgical Unit
Item Type DNP Project
Authors Khandagale, Usha
Publication Date 2021-05
Abstract Problem: In-hospital falls result in patient harm which includes minor injury, psychological distress and anxiety, and serious injuries like fractures, head trauma, and even death. The Joint Commission consistently ranks falls with serious injury as ...
Keywords Tailoring Interventions for Patient Safety (TIPS); Accidental Falls--prevention & control; Inpatients; Quality Improvement
Download date 02/08/2022 00:19:56
Link to Item http://hdl.handle.net/10713/15802
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 1
Implementation of a Fall Prevention Toolkit on a Medical Surgical Unit
Usha Khandagale
Under Supervision of
Brenda Windemuth
Second Reader
Kathleen Buckley
A DNP Project Manuscript
Submitted in Partial Fulfillment of the Requirements for the
Doctor of Nursing Practice Degree
School of Nursing, University of Maryland at Baltimore
May 2021
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 2
Abstract
Problem: In-hospital falls result in patient harm which includes minor injury, psychological
distress and anxiety, and serious injuries like fractures, head trauma, and even death. The
Joint Commission consistently ranks falls with serious injury as one of the top sentinel
events. An acute care medical surgical unit in a community-based hospital experienced an
increase in the number of falls with an overall fall rate higher than that of peer units.
Purpose: The purpose of this Quality Improvement (QI) project was to implement and
evaluate the benefits of, and staff adherence to, the use of Fall TIPS (Tailoring Intervention
for Patient Safety) toolkit to reduce falls on a medical surgical unit.
Methods: The Fall TIPS toolkit was designed to decrease the patient fall rate in hospitals and
engage patients and their families in a 3-step fall prevention process including performing a
fall risk assessment, creating a tailored fall prevention plan, and executing the plan regularly.
Implementation of a Fall TIPS toolkit with auditing transpired weekly over 10 weeks on a
medical surgical unit. Nurses’ adherence to the Fall TIPS protocol was measured weekly
during implementation.
Results: The results indicated that nurses’ adherence to use of the Fall TIPS toolkit averaged
78%. The run chart analysis of nurses’ adherence did not show any shifts or astronomical
datapoints, and the number of runs was consistent with random variation. However, there was
a 6-point upward trend in the data during weeks 2 to 7, indicating a special cause. Fall rates
during the first two months of implementation were 3.39 and 2.41 per 1000 patient-days
respectively, and dropped to zero during the third month.
Conclusion: Nurses’ adherence to a Fall TIPS toolkit was demonstrated on a medical
surgical unit, which likely resulted in a decreased patient fall rate during the final month of
the project. Additional time will be needed to determine if the practice changes and outcomes
are sustainable.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 3
Introduction
Unfortunately, falling during hospitalization remains common. According to the
Agency of Health Care Research (AHRQ, 2019) falls occurred at a rate of 3-5 per 1000 bed-
days, and an estimated 700,000 to 1 million hospitalized patients fall annually in the United
States. More than one-third of in-hospital falls result in patient harm which includes minor
injury, psychological distress and anxiety, and serious injuries like fractures, head trauma,
and even death (AHRQ, 2019). The Joint Commission’s (2015) Sentinel Event database
consistently ranks falls with serious injury in the top 10. The 2017 Maryland Hospital Patient
Safety Program’s Annual Report showed that falls (27%) were a top-five most adverse
hospital event leading to death or serious disability (2017).
A medical surgical unit at a community-based hospital experienced an increased fall
rate, higher than that of peer units. The unit staff were asked about their view of why patients
fell in the unit. The staff responded that the patients’ falls were due to communication
problems of patients not calling for help when getting out of bed. The director of the unit also
reported that there was inadequate and incomplete information at the bedside and variability
among team members regarding the patients’ fall risk status and the plan to prevent falls.
The Centers for Medicare and Medicaid Services (CMS; 2019) considers falls to be
preventable. Therefore, they are no longer reimbursing costs associated with falls, deeming
them to be events that should not occur during hospitalization. Fall TIPS is a tailored
evidence-informed preventative bedside intervention tool to decrease falls in hospitalized
patients (Dykes et al., 2019). The purpose of this QI project was to implement and evaluate
the benefits of, and staff adherence to, Fall TIPS to reduce fall rates on a medical surgical
unit.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 4
Literature Review
The evidence review supported an implementation of Fall TIPS program focused on
in-patient fall prevention, designed to implement patient safety, predominantly fall
prevention. The literature review emphasized the following themes that supported the Fall
TIPS protocol: (a) Fall TIPS lowered fall rates in hospitals; (b) patient, family, nursing, and
leadership engagement was key to effectiveness of Fall TIPS; and (c) exposure to Fall TIPS
positively influenced patient knowledge, skill, and confidence in managing their own health.
The need to implement patient safety and prevent falls is supported by various
studies. A randomized controlled trial by Dykes et al. (2010) revealed that Fall TIPS by
leveraging Health Information Technology significantly reduced falls by 25% in four acute
care hospitals on more than 10,000 patients, and was particularly effective in patients aged
sixty-five or older. Based on those results, Fall TIPS could prevent one fall per day, 7.5 falls
every month, and 90 falls per year in the intervention units. Dykes et al. (2012) used data
mining and modeling techniques to determine the factors related to falls on intervention units
when Fall TIPS was in place. The results revealed that a fall prevention toolkit rationale was
accurate to decrease falls, but strategies were required to improve patient and care team
adherence to the fall prevention intervention suggested by Fall TIPS. Both studies found that
the Fall TIPS intervention was associated with a significant reduction in the fall rate and
injury rate (Dykes et al., 2017, 2020).
When patient engagement was added to the Fall TIPS protocol and tools were
developed to encourage patient and family engagement, there was a decrease in fall and
injury rates demonstrating an increase in effectiveness of Fall TIPS intervention as patient
engagement increased (Dykes, et al., 2017, 2020). Both studies concluded that engaging
hospital staff and clinical leadership was vital in transforming the evidence-based care into
the clinical workflow. According to Duckworth et al. (2019), the three modalities of Fall
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 5
TIPS: Electronic Health Record (EHR) version, a laminated paper version, and the bedside
display version suggest that each fall TIP modality is effective at engaging patients in the 3-
step fall prevention process that includes:
1. Performing fall risk assessment.
2. Creating a tailored fall prevention plan.
3. Executing the tailored fall prevention plan regularly.
A mixed method study by Leung et al. (2017) found that fall risk and fall prevention icons for
a beside toolkit facilitated patient, family and care team engagement to accurately assess fall
risk and a tailored fall prevention plan, resulting in enhanced adherence to Fall TIPS and
reduced falls. A multisite qualitative study conducted by Carter et al. (2020) supported that
one of the barriers to Fall TIPS adoption was poor patient engagement routines among staff
resulting in limited patients’ active participation in fall prevention. Successful execution of
Fall TIPS adoption required staff engagement of patients. Both studies revealed that patient
engagement in the 3-step fall prevention process increased the effectiveness of Fall TIPS
intervention and fall prevention (Carter et al., 2020; Duckworth et al., 2019).
Both studies by Dykes et al. (2017) and Fowler and Reising (2021) included pre- and
post-survey results that showed that Fall TIPS adoption improved patients’ knowledge of the
falls risk factors and fall prevention plan. Improved patient knowledge resulted in a decrease
in fall rates. A multisite study by Christiansen et al. (2020) showed patient activation, which
refers to a patient’s understanding, ability, and self-confidence in overseeing his or her own
health, increased from pre-intervention to post-intervention at the three healthcare system
sites with the access to Fall TIPS. However, it was vital that care team members engaged
patients in their fall prevention plan to increase knowledge, confidence and skill.
Based on an evidence review, adoption of a Fall TIPS program on high fall-risk units
lowered fall rates; improved patient, family, nursing and leadership engagement in the 3-step
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 6
fall prevention strategies; and influenced patients’ confidence in managing their own health
(see Appendix A).
Theoretical Framework
Kurt Lewin’s Change theory was utilized to guide this quality improvement project.
There were three main stages to Lewin’s Change Theory: unfreezing, changing, and
refreezing (Lewin, 1947). Unfreezing included creating a motivation to change the current
practice and preparing for a change. According to Shirey (2013), a change agent is required.
For instance, a nurse leader seeing a problem, and activating others to see the need for
change. In the changing or moving stage, a comprehensive plan of action was created and
staff were willing to try out the action plan. Refreezing entailed sustaining the change so that
it became ingrained into the existing systems such as policies and practices.
The problem identified during the unfreezing stage was increased number of falls in
the medical surgical unit. The change needed was to implement Fall TIPS—a fall prevention
toolkit. The unfreezing stage consisted of identification of stakeholders who had a direct
impact on the success of the project, engaging stakeholders in adopting the Fall TIPS toolkit
(Falls TIPS Collaborative, n.d.), and sharing evidence-based findings on Fall TIPS with the
stakeholders and QI team during the Fall Task Force meetings and huddles. Motivation was
needed to change the current practice which lacked personalized fall risk assessment and a
fall prevention plan. This was accomplished by engaging patients and their families in their
personalized fall risk and fall prevention plans. The changing stage included the
implementation of Fall TIPS. During this stage the stakeholders, champions and unit staff
received education on implementation of Fall TIPS protocol. After training, the need for
change was created and staff training on the Fall TIPS protocol was accomplished. The 3rd
stage, refreezing, involved stabilization of the change when FALL TIPS became a standard
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 7
for the medical surgical population. The utilization of Lewin’s Change Theory was vital to
guiding the implementation of the QI project.
Methods
The purpose of this quality improvement project was to implement the Fall TIPS
(Tailoring Interventions for Patient Safety) toolkit, developed by the Falls TIPS Collaborative
at Brigham and Women’s Hospital and Harvard Medical School (Falls TIPS Collaborative,
n.d.). The project was carried out at a community-based hospital in a 32- bed acute care
medical surgical unit with patients having orthopedic, neurological and oncology conditions.
Inclusion criteria required that patients be hospitalized for at least one day and be alert and
oriented. A 66-member care team was involved in this project. Included were day and night
shift change champions (i.e., five Nurses, three Certified Nursing Assistants or CNA’s, one
Physical Therapist, one Occupational Therapist and two Housekeeping staff), 38-unit nurses
and 16 CNA’s.
The Fall TIPS readiness implementation checklist was used to guide hospital
leadership and staff to prepare for the implementation (see Appendix B). The practice change
was implemented by the nurses over 10 weeks following a 2-week period in which training
was completed (see Appendix C). A completed description of implementation of the Fall
TIPS process was shown in Table 1. A written commitment was obtained from change
champions for adoption; and spread of the new innovation as shown in Appendix D. The
lesson plan was executed for Fall TIPS education (see Appendix E). Pre-implementation
training on the Fall TIPS protocol occurred for day and night shift in twelve separate formal
presentations until the entire unit of 66 staff and stakeholders received education. Fall TIPS
training included: a PowerPoint presentation, handouts, educational binders, performing an
accurate Morse Fall Scale (MFS) assessment, the 3-step Fall prevention process, and one-to-
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 8
one case study review with role play of nurse-patient interaction. Nurses received the Fall
Prevention Knowledge Test (FPKT) (see Appendix F) to evaluate perceived knowledge in
fall prevention. The paired pretest and posttest FPKT were based on True and False response
with the coding option of 1 for the right and 0 for the wrong answer. Permission to utilize the
Fall TIPS toolkit was granted by the Fall TIPS study group as documented in Appendix G.
The practice change was initiated subsequent to 2-week training. Over the following
10 weeks, nurses utilized the laminated Fall TIPS poster (11x17 inches) to engage and
educate eligible patients and their families in the three-step fall prevention process (see
Appendix H). The poster was hung on the door across the patient’s bed for visibility. Nurses
updated the poster daily on the patient’s current status and reviewed the information on the
tool at least once per shift and as needed. The Fall TIPS Quality Audit Instruction was used
to guide the audit process (see Appendix I). Data was collected through observation by
change champions weekly using the Fall TIPS Quality Audit Tool, which measured the
nurse’s adherence to, and patients and families engagement in the fall risks and prevention
plan (see Appendix J). The paper pencil tool extracted anonymous data. The first 3 questions
require a yes/no response by the auditor. If there was a “no” response to any of the first 3
questions, then the auditor was asked if they had provided peer-to-peer feedback to the staff.
The 3 questions included the Fall TIPS poster hanging on the door across from the patient’s
bed with a correct date, while patient and family were required to verbalize fall risk factors
and the fall prevention plan. Peer-to-peer feedback was provided if any question was
answered “No”. The completed data was entered in the REDCap electronic data capture tools
hosted at University of Maryland, Baltimore. The monthly fall rate per 1000 patient-days was
tracked from Quality Services department.
The project leader retrieved the de-identified pretest and the posttest FPKT responses
from REDCap; and ensured that responses were matched by using paired t-test. Nurse’s
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 9
adherence to ensuring Fall TIPS toolkit was complete with correct date, risk factors and fall
prevention plan and family engagement on knowledge of fall risk and prevention was
calculated in percentages. A project summary was submitted to the University of Maryland
Baltimore Human Research Protections Office (HRPO) for a Non-Human Subjects Research
(NHSR) determination. The results of the Fall TIPS Quality Audit Tool was stored on an
internal password protected computer.
Results
The pre-implementation education on Fall TIPS protocol occurred in 12 separate face-
to-face formal sessions. A total of 43 nurses received education. Nurses received the FPKT to
evaluate their perceived knowledge in fall prevention. A paired t-test was utilized to assess
the nurses’ perceived knowledge in fall prevention pre- and post-education. The results from
the pre-test (M = 0.42, SD = 0.098) and post-test (M =0.42, SD =0.135) for the FPTK
indicated that the training resulted in no significant improvement in the nurse’s knowledge
t=0.00 p = 1.00.
The nurse’s adherence to fall TIPS on the 3 question yes/no response was analyzed on
a weekly basis as shown in the run chart in Figure 1. Change champions performed a total of
259 Fall TIPS Quality Audits. The 194 observations recorded on the Fall TIPS audit were
100% complete. The overall nurse’s adherence rate for the 10 weeks of implementation was
78%; the target goal was set at 100%. The preliminary adherence rate during the first three
weeks of implementation was 56%, 61.5% and 73.9% respectively and progressively
improved to 96% at the end of 10 weeks. Run chart analysis did not show any shifts or
astronomical datapoints, and the number of runs was consistent with random variation.
However, there was a 6-point upward trend in the data during weeks 2 to 7 demonstrating a
non-random pattern due to a special cause (see Figure 1).
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 10
The monthly pre- and post-implementation of fall rate per 1000 patient-days data was
tracked from the hospital Quality Services and analyzed in a run chart (Figure 2). Prior to
implementation the fall rates for the months of July and August were 2.19 and 4.59 per 1000
patient-days respectively. Fall rates during implementation in the months of October and
November were 3.39 and 2.41 per 1000 patient-days respectively. No falls occurred in the
month of December. Run chart analysis did not show runs, shifts or trends. However, there
was an astronomical point noted in the month of December when there were no falls.
Discussion
The aim of this project was to decrease falls by improving patient engagement in fall
risks and fall prevention plan with communication across care team members. Although all
the nurses were trained on the Fall TIPS protocol, their lack of improvement in scores on the
post-test may have been due to nurses’ fatigue. The project took place during the COVID-19
pandemic, and the medical surgical unit was experiencing increased patient acuity and
census, high staff turnover, and shortage of staff, and constant change. Competing demands
on nursing staff to complete annual competencies also created challenges and time
constraints on the implementation. The barrier of lack of awareness and familiarity to the new
protocol, despite being trained on Fall TIPS protocol, was addressed by the project leader and
nurse champions providing “Just-in-time” training sessions to all staff, to remedy concerns
and answer questions. This tactic was similar to one used by Dykes et al. (2017) who
developed and implemented the Fall TIPS toolkit.
Strategies to overcome the low adherence rate to the protocol during the first three
weeks of the project included, constant communication with the unit staff by spreading
awareness, removing knowledge barriers by small group discussion and one-on-one
education. Daily shift huddles, staff meetings, a fall prevention bulletin board, and study
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 11
references at both nurse’s stations offered verbal and visual occasions for communication
about falls. Engagement of leadership at the unit level improved awareness of the new
evidence. These approaches were comparable to those used by Carter et al. (2020) who
identified engagement of leadership commitment, staff and patients was key in transforming
effective adoption of Fall TIPS. Involving unit change champions to provide peer-feedback,
reeducation, and promoting consistent application and adoption of Fall TIPS improved
awareness.
The results indicated that the strategies and tactics used had a positive impact on the
nurses’ adherence to the Falls TIPS toolkit. The nurses reached their highest adherence rate
of 96% the first week of December. This may have been due to multiple reasons that included
the unit director requiring nurses to complete the Fall TIPS poster at the bedside during the
change of shift handoff. The Assistant Nurse Manager (ANM) and charge nurses also began
performing random spot checks daily by observation during each shift, for completion of the
Fall TIPS poster. The dramatic shift in the fall rate to no falls during the month of December
was also likely related to this high adherence rate. Other reasons that may have contributed
to these positive findings included the improvement of the fall communication among care
teams, patients and families. Nurses were in agreement that the Fall TIPS was an effective
prevention tool as it engaged patients and families in their prevention process. Patients
increased their rate for calling for assistance for getting out of bed or with toileting, due to
enhanced awareness of fall risks factors and the fall prevention plan. This result was
comparable to the findings by Fowler and Reising (2021) who suggested that with the Fall
TIPS adoption there was improved patients’ knowledge of their fall risk factors and fall
prevention strategies.
While there was a decline in the fall rate per 1000-patient days, from a high of 3.39 in
October to zero in December, more time is needed to determine if this decline will continue
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 12
beyond implementation. It is probable that an increase in the nurses’ adherence to the Fall
TIPS protocol affected the unit fall rates. The results were comparable to the previous studies
by Dykes et al. (2010) and Dykes et al. (2012), which demonstrated that the adoption of the
Fall TIPS toolkit as associated with a decrease in fall rates. All fall risks patients were put on
bed alarms as per hospital policy, which may have contributed to alarm fatigue and noise in
the environment and possibly resulted in falls. This concern resulted in the decision by the
project leader and stakeholders to not use bed alarms on every patient at risk for falls, which
is consistent to the approach taken by Dykes et al., (2018) in their implementation of the
toolkit. However, patients who were not reliable to call for help when required, were placed
on a bed alarm.
The findings of this QI project are not generalizable to other settings and are limited
to a single patient unit with medical surgical patients at the center. Due to the pandemic
nurses expressed fatigue due to constant new changes, which may have limited their
adherence to the fall prevention measures.
Conclusion
Overall, the Fall TIPS toolkit was beneficial and effective in enhancing the awareness
of unit staff on the medical surgical unit and increasing nursing adherence to fall prevention
measures. The Fall TIPS poster completion and engagement of patients and their families
appeared to have an impact on reducing patient falls for the final month of the project. The
project results also revealed increased engagement of patients and their families to identify
fall risk factors and related prevention plan.
There is an increased prospect for sustainability of the project. The stakeholders have
been involved from the start of the project and have shown great interest during the entire
implementation process. There was significant leadership support and nurses taking the role
of change champions by performing audits, providing peer-feedback, reeducating, and
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 13
promoting adoption and consistent application of Fall TIPS. The clinical nurse specialist
continues to perform periodic spot checks 3-4 times per week on the unit for adherence to the
Fall TIPS protocol. The unit secretaries are ensuring the availability of the Laminated Fall
TIPS posters in English and Spanish and dry-eraser markers. While these enhanced
engagements suggest a culture prepared to support a new evidence-based practice change,
additional time will be needed to determine if the practice changes and outcomes are
sustainable.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 14
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IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 17
Table 1
Description of Implementation Process of Fall TIPS toolkit
Motivating change • Engaged stakeholders in adopting the laminated paper Fall TIPS poster as an evidence-based tool to decrease falls
• Presentation of the evidence was performed in Fall Task Force meeting, leadership meeting and staff unit huddles
• Quality Services involved for monthly fall rate information
• Identified champions for day and night shift
Planning and set up • Set up for adoption and spread was performed by targeting patient population in the medical surgical unit with high fall rate
• Supported secured from unit level leadership which included unit director, ANM, and Charge Nurses
• Fall TIPS readiness implementation checklist was used to guide the quality improvement project
• Utilized native communication such as staff meetings and morning and evening huddles to spread the innovation
Education • Unit staff received pre-implementation training on Fall TIPS protocol with Fall TIPS instruction sheet
• Nurses completed the Fall pre and post paired FPKT
• Nurses utilized the Laminated Fall TIPS poster to engage patients and their families in the three-step fall prevention process
• Train-the-trainer sessions were utilized for new staff and staff identified as having poor completion rate for Fall TIPS
• Fall TIPS information sheet was provided to patients
Establishing Care
goals • Change champions performed audits to measure adherence rate and
patient compliance to Fall TIPS
• Change champions provided prompt feedback to nurses as needed post audit
• Change champions were taught to assist with training
• Adherence to the Fall TIPS was performed by weekly spot checks in the unit to observe whether Fall TIPS is complete with correct date,
risk factors and prevention plan
Continuous
monitoring and
feedback
• Continued the spread and utilization of Fall TIPS by engaging leadership, unit director, ANM charge nurses and clinical nurse
specialist,
• Biweekly report shared with unit staff, director and committee leaders on adherence to Fall TIPS protocol, patient/family engagement and fall
rates
• Staff meeting and huddle time was utilized to improve awareness and adherence rate
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 18
Figure 1
Medical Surgical RN Compliance to Fall TIPS Run Chart
Median
Goal
0
20
40
60
80
100
120
S e
p t-1
2
S e
p t-1
9
O c t-3
O c t-1
0
O c t-1
7
O c t-2
4
O c t-3
1
N o v -7
N o v -1
4
N o v -2
1
N o v -2
8
D e c -5
P e
rc e
n ta
g e
o f F
a ll T
IP S
C o
m p
le te
d
% of nurses compliant with protocol
Medical and Surgical RN Fall TIPS Compliance
Values Median GoalPre-implementation Implementatoion
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 19
Figure 2
Fall Rate for the Medical Surgical Unit
Median
Goal0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
5.00
J u l-2
0
A u
g -2
0
S e
p -2
0
O c t-2
0
N o v -2
0
D e c -2
0 Fall Rate per 1000 Patient Days for Medical Surgical Unit
F a
ll R
a te
p e
r 1
0 0
0 P
a ti
e n
t D
a ys
f o
r M
e d
ic a
l S
u rg
ic a
l U
n it
Implementation
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 20
Appendix A
Evidence Review Table that evaluates Fall TIPS and interventions among medical surgical patients Carter E. J., Khasnabish, S., Adeleman, J. S., Bogaisky, M., Lindros, M. E., Alfieri, L., Scanlan, M., Hurley, A., Duckworth, M.,
Shelley, A., Cato, K., Shao P. Yu., Carroll, D., Jackson, E., Lipstiz, S., Bates, D. W., & Dykes, P. C. (2020). Adoption of a Patient-
Tailored Fall Prevention Program in Academic Health Systems: A Qualitative Study of Barriers and Facilitators. OMB Geriatrics,
4(2), 1-15 http://www.lidsen.com/journals/geriatrics/geriatrics-04-02-119
Level VI
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
“We aimed to
identify dominant
facilitators and
barriers to Fall TIPS
adoption”
A Multisite qualitative
study design
Sample Technique:
Convenient sampling
Eligible:
Staff N-71
Patients N=50 and
Family members N=7
Eligible participants:
Patients were
considered eligible if
they spoke English or
had a family member
who spoke English and
who were alert and
oriented.
Eligible patients were
chosen by healthcare
team.
They had to have no
prior relationship with
the study examiner.
Excluded: none
reported
Accepted:
A sum of 71 staff took
part in 11 focus groups.
There were 50 patients
and 7 family members
individually
Intervention Protocol:
Patients’ families were
interviewed
individually for 15-60
minutes.
The focus groups that
ranged from 3-10
participants interview
extended 30-60 minutes
Intervention fidelity:
Staff focus and patients
interview conducted in
2 phases
Phase 1- principal
barriers and facilitators
for Fall TIPS identified
Findings discussed with
major stakeholders to
examine for accuracy.
Phase 2 – Continued till
findings from phase 1
were validated or
rejected.
Two to three
investigators performed
the interviews and
focus groups at each
study.
Dependent variable:
Fall TIPS adoption
barriers and facilitators
Measures:
The dependent
variables were
measured
after participants
consented verbally,
audio recordings of
interviews were made.
Their responses were
transcribed verbatim by
an automated
transcription aid.
For transcription
validity, transcripts
were scrutinized by
both the study
coordinator and
investigator.
Researcher’s job
included mutual
identification of codes,
application of codes
and discussion of any
discrepancies to reach
an agreement.
Statistical results:
Interviews were
analyzed utilizing
Conventional Content
Analysis.
Coding was executed
within NVivo using
consensus approach.
Facilitator’s
identified to Fall TIPS
adoption included 1)
Staff understanding of
the previous limitation
of fall prevention
programs and
recognizing fall
prevention as a priority
2) Patients and their
families took part in the
fall prevention
3) Fall TIPS was
incorporated in staff
existing workflow.
Barriers to fall TIPS
adoption program
included
1) Poor engagement
practices among staff
resulted in limited
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 21
interviewed during the
study period.
Power Analysis: No
power analysis was
reported which
increased the risk of
making a Type II error.
Group Homogeneity:
The study participant
group homogeneity was
presented in table 2, for
demographics.
Investigators attended
continued accepted
education workshop
directed by two
qualitative research
experts.
Patient confidentiality
was maintained during
individual interviews.
Group exchange and
dialogue was promoted
in the staff focus
groups.
For ensuring validity of
the results, researchers
peer debriefed biweekly
to seek objectivity of
findings, member
checking, involved
discussion of
qualitative findings
with patients and staff
for accuracy.
patients’ activation in
fall prevention
2) Using the one size
fits all viewpoint in fall
prevention
3) Patient’s willfulness
of not following the fall
plans.
Christiansen, T. L., Lipsitz, S., Scanlan, M., Yu, S. P., Lindros, M. E., Leung, W. Y., Adelman, J., Bates, D. W., & Dykes, P . C.
(2020). Patient Activation Related to Fall Prevention: A Multisite Study. The Joint Commission Journal on Quality and Patient
Safety, 46(3), 129–135. https://doi10.1016/j.jcjq.2019.11.010
Level IV
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
“The primary aim of
this study was to
determine if exposure
to the Fall TIPS
program influences
patient activation
related to fall
prevention”
Pre and post
implementation design, a
multi-site study
Sample Technique:
Simple random sample
technique
Eligible participants:
Adult patients, aged >
18 years admitted to the
study units for a
minimum of 24 hours.
Patients who were
mentally and physically
able to participate.
Participants were alert
and oriented, able to
speak English, gave
verbal consent to take
the survey, and
voluntarily participated.
Excluded: were 7
patients who did not
respond to the survey
Intervention Protocol:
Patient activation was
graded by surveying a
random sample of adult
patients before and after
employment of Fall
TIPS at three health
care system.
Intervention Fidelity:
Researchers used the
short form Patient
Activation Measure
(PAM– 13) adapted for
fall prevention.
The 13-item survey
assessed a patient
knowledge, skill, and
self-reliance in
managing his or her fall
prevention.
Dependent
Variable(s):
Patient activation refers
to a patient’s
knowledge, skills and
confidence in managing
his or her own health.
Measurement tool
(reliability), time,
procedure:
Patient’s activation was
measured by the
The PAM is a 13-item
(short form) assessed
patient activation in
four different levels.
Level 1 is the lowest
level of activation and
level 4 is the highest
Patients with a score of
1 are considered
Statistical
Procedures(s):
A reliability analysis
using Cronbach’ alpha
was used for reliability
analysis and showed
that scale is reliable (α
= 0.870 pre; α 0.870
post)
The robust ordinal t-test
revealed an increase in
PAM scores between
groups overall, with the
preintervention mean
scores at 63.82 (SD +
17.35)
The post intervention
means scores at 80.88
(SD + 17.48), p <
0.0001
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 22
(response rate of
98.0%).
Exclusion criteria:
Patients, who were not
mentally and physically
able to participate, who
were below 18 years of
age and discharged
before 24 hours after
admission.
Accepted: 343 patients
across three sites
n=158 preintervention;
n=185 postintervention.
Intervention: 343
patients were randomly
assigned.
Power Analysis: No
reported power
analysis, increasing the
risk of a Type II error.
Group Homogeneity:
The pre and post
intervention group
homogeneity is
presented in Table 1 &
2 which represents
descriptive statistics of
patients’ baseline
characteristics.
overwhelmed and
disengaged, in
managing their health.
The short form is both
valid and reliable
instrument.
The PAM 13 uses a 4-
point Likert scale (1=
strongly disagree and 4
= strongly agree).
Results:
Patient’s activation
increased from pre to
postintervention at all
sites Brigham and
Women’s Hospital
(BWH), p < 0.0001;
Montefiore Medical
Center (MMC), p <
0.0001 and
New York-
Presbyterians (NYP), p
= 0.0373
Duckworth, M., Adelman, J., Belategui, K., Feliciano, Z., Jackson, E., Khasnabish, S., Lehman, I.-F. S., Lindros, M. E., Mortimer,
H., Ryan, K., Scanlan, M., Berger Spivack, L., Yu, S. P., Bates, D. W., & Dykes, P. C. (2019). Assessing the Effectiveness of
Engaging Patients and Their Families in the Three-Step Fall Prevention Process Across Modalities of an Evidence-Based Fall
Prevention Toolkit: An Implementation Science Study. Journal of Medical Internet Research, 21(1), e10008.
https://doi.org/10.2196/10008
Level IV
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 23
“The purpose of this
study is to assess the
effectiveness for
engaging patients and
family in the 3-step
fall prevention process
(as defined by
patient/family
knowledge of their
personalized fall risk
factors and prevention
plan) of each of the
Fall TIPS modalities”
Single Qualitative
Descriptive Study
Sample Techniques:
Random sample of
Audits conducted by
Champions across all
data collection sites
6 Neurology units
7 medical or medical-
surgical units
Eligible Participants:
N=1209
Accepted:
1209 audits on patient
engagement
1401 audits for the
presence of the Fall
TIPS poster at the
bedside.
Inclusion Criteria:
Patients must be aged ≥
18 years, alert and
oriented or have a
family member present
and being involved in
the care, English or
Spanish speaking; and
Length of Stay (LOS)
in hospital > 24 hours.
Excluded criteria:
Patients who were < 18
years and not alert and
oriented and did not
have a family at the
bedside were excluded
from the study.
Power Analysis: No
power analysis was
reported which
increased the risk of
making a Type II error.
Intervention Protocol:
Engagement of patient
in the 3-step fall
prevention process
across the 3 Fall TIPS
modalities, patients
were questioned about
their knowledge of their
fall prevention plan.
Intervention Fidelity:
Each site incorporated
the Fall TIPS
prevention process into
practice,
built the clinical
decision support by Fall
TIPS into the electronic
health record (EHR)
Nurses completed the
fall TIPS risk
assessment and tailored
plan and recorded in
her at each site of data
collection.
The 3 modalities
utilized to present and
communicate the
patient’s falls risk
factors and fall
prevention plan
included
1. The laminated Fall TIPS poster
2. Electronic Fall TIPS poster
3. Paperless patient safety bedside
display
Dependent variable:
Patients and family’s
knowledge about their
personal fall risks
factors and their fall
prevention plan around
the 3 Fall TIPS
modalities.
Protocol adherence
measured as the display
of fall prevention plan
at bedside
Measurement tool
(reliability), time,
procedure:
Random audits
performed to check the
effectiveness of
engaging patients in the
3-step fall prevention
across the 3 modalities
by asking does
patient/family know
their fall prevention
plan?
Radom audits were
performed to measure
protocol adherence by
checking if Fall TIPS at
the bedside
Nurse champion
selected patients for
audits.
Unannounced audit was
performed weekly.
Display of the
personalized fall
prevention plan at the
patient’s bedside was
Results:
Each Fall TIPS
modalities was
efficiently to assist
patient engagement in
the 3-step fall
prevention method
rate (> 80%) of
adherence for both
measures. i.e., of
patient engagement and
of adhering to protocol
of Fall TIPS.
Recommendations are
that all 3 modalities can
be incorporated in the
clinical workflow.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 24
Group Homogeneity:
The sample population
consisted of a diverse
group of patients. At
Brigham’s and
Women’s Hospital
(BWH), Montefiore
Medical (MMC)
37.78% comprised of
Hispanics. Average age
groups of patients at the
3 study hospitals
(namely, BWH, MMC,
and New York
Presbyterian Hospital)
were 60.5, 60.1 and
63.3 years, respectively.
an indication of
adherence to the Fall
TIPS protocol
Dykes, P. C., Burns, Z., Adelman, J., Benneyan, J., Bogaisky, M., Carter, E., Ergai, A., Lindros, M. E., Lipsitz, S. R., Scan lan, M.,
Shaykevich, S., & Bates, D. W. (2020). Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries: A
Nonrandomized Controlled Trial. JAMA Network Open, 3(11), 1-10. https://doi.org/10.1001/jamanetworkopen.2020.25889
Level III
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
“The goal of the trial
was to assess whether
a fall-prevention tool
kit that engages
patients and families
in the fall-prevention
process throughout
hospitalization is
associated with
reduced falls and
injurious falls”.
A Nonrandomized
Controlled Trial with
pre- and post-
intervention study
Sampling Technique
Convenient sample
design at 14 medical
units including 3
academic medical
centers.
Eligible Participants:
N=37231
Eligible criteria:
All adult inpatients who
were hospitalized were
involved in the study.
Excluded: None
Sample size: N-37,231
pre-intervention 17948
and post intervention
19283
Intervention
Participants were
continuously engaged
by nurses in the 3-step
fall prevention process.
Intervention Fidelity
A laminated Fall TIPS
poster displayed at the
bedside
Nurses completed
poster with dry eraser
markers with patient
/families at admission
and during every.
The research team
assigned start dates to
each unit with the Fall
Dependent variables:
The two main outcomes
included overall rate of
patient falls per 1,000 s
and overall rate of falls
with injury per 1,000
days.
Measurement tool
(reliability) time,
procedure:
Nurse champions
completed
competencies training
and monitored fidelity
Unit nurse champions
measured compliance
to the Fall TIPS
A Poisson regression
tool used to establish
association between
intervention and the
rate of patient falls and
falls with injury per
1,000 days.
In addition, in
secondary analysis
adjusted Poisson
regression model was
used to assess changes
before and after
intervention included,
fall rates with
interaction involving
age groups and period,
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 25
Group Homogeneity
Demographic
characteristic of
patient’s was presented
in Table
Power Analysis:
No power analysis was
reported which
increased the risk of
making a Type II error.
TIPS modality along
with the constraints,
based on the 3
modalities.
Nurses identified the
patients Fall risk by
using the MFS and
linking the risk factors
with the suitable fall
prevention plan.
In the EHR-toolkit the
clinical decision
support spontaneously
printed appropriate
preventive
interventions.
Automatic displayed
screen saver at bedside,
were effective in testing
patient engagement in
the 3-step fall
prevention protocol
A 21-week pre-
intervention period
followed by 21-week
post intervention
period.
protocol including
patient engagement and
auditing 3 question
1) Is the Fall TIPS
poster complete and has
the correct information,
2) Can patient/family
verbalize fall risk
factors and
3) does the
patient/Family
verbalize the fall
prevention plan.
Nurses completed 5
random audits per
month with the Fall
TIPS Audit tool.
and interaction between
site and period.
An alpha level was set
at p<005.
There was an overall
15% adjusted decrease
in falls post
implementation of Fall
prevention toolkit
compared with
implementation (2.92
vs 2.49 falls per 1000
patient-days [(95% Cl,
2.06-3.00 fall per 1000
patient-days)].
An adjusted 34%
decreased injury rate
(0.73 vs 0.48 injurious
falls per 1000 patient-
days [95% Cl. 0.34 -
0.70 injurious falls per
1000 patient-days];
adjusted rate ratio 0.66;
95% Cl. 0.53-0.88; p=.
003).
Conclusion:
Implementation of Fall
prevention Tool kit was
related with a
significant decrease in
falls and related injury.
Citation: Dykes PC, Carroll DL, Hurley A, Lipsitz S, Benoit A, Chang F, … Middleton. (2010). Fall prevention in acute care
hospitals: a randomized trial. JAMA: Journal of the American Medical Association, 304(17), 1912–1918.
https://doi.org/10.1001/jama.2010.1567
Level II
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
“To investigate
whether a fall
Cluster randomized trial
design
Sampling Techniques:
Convenient sampling
Control Protocol: Dependent variable: Statistical results:
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 26
prevention tool kit
(FPTK) using health
information
technology (HIT)
decreases patient falls
in hospitals”.
from Medical units with
fall rates higher than
the mean for the
institution the year
before the study were
matched to units with
similar fall rates and
patient-days. Eligible: N=10264
patients
Eligibility Criteria:
Units that matched and
were not involved
specifically in other fall
prevention
improvement projects
were deemed eligible.
Excluded: 8 units did
not meet eligibility
criteria.
Accepted: 10264
patients in the medical
units with high fall
rates. Randomization
located patients in the
in each of the control or
the intervention group.
Control: 5160 patients
in 4 units that received
standard care
Intervention: 5160
patients in 4 units that
received the
intervention
Power analysis: 10264
patients expected to
meet 80% power (with
α =.05) with fixed
effects size. Power
Control units received
routine care associated
with fall prevention
which included:
Completed MFS using
paper or electronic
forms
Placing high risk fall
sign above patients’ bed
with MFS scores > 45
Education of
patients/family on falls
with a booklet or
handout
Documenting plan on
electronic or paper
Intervention Protocol:
Included interventions:
Completed MFS
utilizing Fall
Prevention Toolkit
(FPTK)
Personalized bedside
posters were printed
spontaneously and
placed above patients’
beds
Educated patient/family
with tailored handout
Followed tailored plan
generated
spontaneously
generated by FPTK
from MFS assessment
Treatment Fidelity:
The research team
developed software for
the FPTK.
Falls per 1,000 patient-
days
Falls with injury per
1,000 patient-days in
the targeted units
Patient falls specified as
an unplanned descent to
the floor throughout the
hospitalization
Measurement tool
(reliability). Time,
procedure:
The dependable
variable measured by:
reporting patients falls
and falls with injury
recorded in an event
report system in the
units by nurse taking
care of the patient.
Incidents were
validated by hospital
quality personnel and
unit managers.
Valid Fall Risk
Assessment Scale
(MFA) identified
patient on high fall
risks.
Adherence to the Fall
prevention protocol was
measured by random
review of MFS
completion in control
groups and use of
FPTK components
including MFS
completion in the
intervention groups.
To examine the
difference in falls
throughout intervention
and control group the
priori Poisson
regression model
utilized that contained a
fixed effect and
intervention effects for
hospital.
Patient characteristic
was calculated utilizing
proportions, means with
standard deviation and
median with
interquartile ranges.
Covariate balance was
checked utilizing the
stratified Wilcoxon test
for continuous
confounders and fixed-
effects multinomial
logistic regression for
categorical confounders
A priori Poisson
regression model with
fixed effect and
intervention effect for
hospitals was utilized to
examine the difference
in falls throughout
intervention and control
groups.
The stratified Wilcoxon
test was used to check
the covariate balance.
Factors tested were
continuous confounders
and fixed-effects
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 27
analysis met to reduce
risk for type II error.
Group Homogeneity:
The Participants
characteristic of the
control and
interventional groups is
based on descriptive
statistics summarized in
table 2.
The FPTK (Fall
Prevention Toolkit)
incorporated the current
workflow patterns and
communication in the
Health Information
Technology (HIT)
operations.
According to the Morse
Fall Scale (MFS) risk
assessment completed
by the nurse, the FPTK
software generated
personalized fall
prevention
interventions per the
patient’s specific fall
risk.
The FPKT generated
bed posters include,
short text with
associated icons, care
plan, education
handouts, and all
patient specific
notifications to patients
to stakeholders.
The FPTK included a
compliance dashboard
to assist monitoring.
multinomial logistic
regression for
categorical
confounders.
There were lesser
patients with falls in the
intervention units
(n=67; range across
units 10-28) compared
with the control units
(n= 87; range across
units, 15-33).
A significantly lower
adjusted rate was found
in the intervention units
fall rate of 3.15 [95%
confidence interval
(Cl), 2.54 -3.90] per
1,000 patient-days). By
comparison the control
units’ results were 4.18
[95% Cl, 3.45-5.06] per
1,000 patient-days, with
rate variance of 1.03
(95% Cl, 0.57-2.01) per
1000 patient-days
(p=.04).
Patients aged 65 years
or older derived the
most benefit from the
FPTK Adjusted rate
difference, 2.08 [95%
Cl, 0.61-3.56] per 1,000
patient-days p=.003).
No significant effect
was noted in the injury
rates.
In the 8 study units,
including control and
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 28
intervention, there were
two 862 patient-days
periods.
Results showed that
the FPTK can prevent 1
fall per 862 patient-
days. Hence, the FPTK
could possibly prevent
approximately 90 falls
every year in
intervention units.
equating to 7.5 falls
every month and 1 fall
every 4 days.
Dykes, P. C, I-Ching, E. H., Soukup, J. R., Chang, F., & Lipsitz, S. (2012). A case control study to improve accuracy of an
electronic fall prevention toolkit. AMIA ... Annual Symposium Proceedings. AMIA Symposium, 2012, 170–179. https://www-
ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pmc/articles/PMC3540550/
Level IV
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
“The purpose of this
case control study was
to use data mining and
modeling techniques
to identify the factors
associated with falls in
hospitalized patients
when the toolkit was
in place. Our ultimate
aim was to apply our
findings to improve
the toolkit logic and to
generate practice
recommendations”
A Case Control Study Sampling Technique
Cases included patients
with a fall on
intervention units at 4
partners HealthCare
acute care hospitals.
Controls randomly
selected from
intervention units
without a fall
Eligible Participants
Cases: Inpatients that
fell on the intervention
unit in an acute care
hospital where the Fall
TIPS toolkit (FTTK)
was in place for a 6-
month period. Cases
Intervention
Faller were matched
with similar controls in
regards to gender, age,
first MFS, length of
stay till the fall
Reviewed patients’
medical records and
incident report of falls
when FTTK in place
Checked for problems
with the FTTK software
to be corrected
Checked for the
intervention plan
suggested by FTTK
was correct and was
followed as by
Dependent variables:
Factors associated with
falls such as out of bed
with assist, 1 and 2-
person assist, Chair/Bed
alarm,
reorientation/frequent
checks, bed close to the
nursing station.
Measurement tool
(reliability). Time,
procedure:
A nurse investigator
extracted clinical data
for each case and
controls from the FTTK
database comprising
demographics, and
Morse Fall Scale (MFS)
Descriptive statistics by
employing two-by-two
tables were produced to
explain demographic
data of cases and
controls including
percentages in each
case/control group.
Conditional logistic
regression was used to
assess differences in
patients’ characteristic
for cases and control.
A priori variable
measured for
multivariate conditional
logistic regression
model comprised the
following significant
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 29
involved if they had 3
or more matches
Controls: Randomly
selected from patients
admitted to the
intervention units in the
same 6 months and did
not have a fall.
Controls were paired
for gender, age (within
5 years), first Morse
Fall Scale (MFS) total
score and length of stay
in the unit (within 24
hours) up to the time of
fall.
Excluded:
1 patient was excluded
due to incomplete data.
Sample size: N-192
88 patients age 64 and
younger
104 patients age 65 and
older
Power Analysis: No
power analysis was
reported which
increased the risk of
making a Type II error.
Group Homogeneity:
Cases and controls with
p value on table 4 for
demographics and
clinical characteristic
clinicians as
recommended by FTTK
Document prior fall,
out of bed with assist,
cane, bed/chair alarm,
1-person assist, 2-
person assist, frequent
checks/orientation, and
bed close to nursing
station.
total scores, nurse’s
interventions (proposed
by the FTTK of
patient’s risk report and
nurse’s knowledge
about the patient).
The nurse investigator
also collected the fall
incident data from
incident reporting
system, comprising unit
length of stay at the
time of fall.
A second investigator
confirmed extraction
for a random selection
of 10% of cases and
controls with agreement
> 90%.
intervention variables
(p<0.05).
All P values were two
tailed and a statistically
significant p value was
<0.05.
Falls: total falls 67 in
the intervention unit.
Of remaining cases: 48
had 3 or more matches
for gender, age (within
5 years), first Morse
Fall Scale (MFS) total
score and length for a
total sample size of
192.
Three research
questions answered,
The univariate
conditional logistic
regression analysis was
completed to answer all
3 questions.
Question One
Why did some patients
on the experimental
units fall with access to
the FTTK?
The univariate
conditional logistic
regression analysis
showed there was a
significant association
for the subsequent 7
interventions:
document prior fall out
of bed with assist
(p=.000)
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 30
bed/chair alarm
(p=.003)
1-person assist (p=.040)
2-person assist
(p=.006)
frequent
checks/reorientation
(p=.025)
bed close to nursing
station (p=.042)
frequent
checks/Reorientation
(p=.025)
The 7 variables were
entered into a
conditional logistic
equation and the
findings recommended
cases (fallers) were 5.7
times more likely than
matched controls (non-
fallers) among patients
requiring assistance
getting out of bed.
Question 2
What factors are linked
with falls associated
with younger patients?
The univariate
conditional logistic
regression analysis
showed significant
association for the
following 5
interventions,
out of bed with assist
(p=.010)
bed/chair alarm
(p=.003)
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 31
1-person assist (p=.034)
frequent
checks/reorientation
(p=.023)
bed close to nursing
station (p=.012)
Nevertheless, after
entering these variables
into the conditional
logistic regression
model and adjusting for
insurance and total
MFS before the fall,
none remained
significant.
Question 3
What factors are
associated with falls in
older patients?
The univariate
conditional logistic
regression analysis
showed significant
association for the
following 3
interventions:
ambulatory aid:
cane (p=.047)
out of bed (p=.004)
two-person assist
(p=.005)
Findings suggest cases
were significantly less
likely than matched
controls to be patients
who prior to fall did not
use a cane as an
ambulatory aid.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 32
Fallers were also 10.1
times more liable than
matched controls before
the fall known to need
assistance getting out of
bed before the fall, and
14.26 times more liable
than non-fallers before
the fall to need 2 people
for assistance when
walking or getting out
of bed.
Results of evaluation
suggested that the
FTTK rational is
accurate but strategies
are needed to enhance
adherence with the fall
prevention intervention
proposals generated by
the electronic toolkit.
Dykes, P. C., Duckworth, M., Cunningham, S., Dubois, S., Driscoll, M., Feliciano, Z., Ferrazzi, M., Fevrin F.E., Lyons. S., Lindros
M. E., Monahan A., Paley M.M., Jean-Pierre S., Scanlan, M. (2017). Pilot testing Fall TIPS (Tailoring Interventions for Patient
Safety): a Patient-Centered Fall prevention Toolkit. The Joint Commission Journal on Quality and Patient Safety, 43(8), 403–413.
https://doi.org/10.1016/j.jcjq.2017.05.002
Level IV
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
Pilot testing the Fall
TIPS (Tailoring
Intervention for
Patient Safety) on
high-risk units at
BWH and at MMC
was to establish
efficacy and a
foundation for
adoption and spread.
Pilot Study Sampling Technique:
Convenient sampling at
two large medical
centers
Eligible Participants:
At Brigham and
women’s Hospital
(BWH)
31 patients answered
the pre-survey
33 the post survey
Intervention Protocol:
Conceptual model used
was The Institute of
Healthcare
Improvement’s (IHI)
Framework for Spread
(FFS). The four phases
of FFS include:
Communication:
The expert team
presented evidence on
Dependent variable:
Fall rate and Fall with
injury rates
Adherence to
Protocol, Fall
Rates/Injury Rates
Compliance to fall
TIPS protocol was
monitored via weekly
spot checks on each
unit
Patient surveys
At BWH; Boston
Changing levels of
progress - from baseline
to post Fall TIPS with
scores - were shown by
results of the Mann
Whitney U test; as well
as capability of patients
in recognizing their fall
risk (pre mean 3.7;
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 33
At Montefiore Medical
Center (MMC)
32 answered the pre
survey
30 patients answered
the post survey
Group Homogeneity:
The majority at BWH
were patients in the pre
and post survey were
female (60%), age 55
years, or older (53%)
and Caucasian (66%).
The majority of patients
in MMC were females
(68%) age 55 years and
older (53%) black or
African American
(53%) and
Hispanic/Latino (32%)
Power Analysis: No
power analysis was
reported which
increased the risk of
making a Type II error.
Fall TIPS to leadership
and quality and nursing
grand rounds to gain
support and
communicate value of
the Fall TIPS.
Planning and set up
Targeting relevant
population: patients on
units with fall rates
above the mean and
above the benchmark
for the institution.
Spread within the
target population
Secured support of unit
level clinical
leadership, unit-based
practice council, and
staff members
Unit champions and
stakeholders identified
and given education
and training for
associated practice
change.
Training sessions were
for all staff.
Continued monitoring
and feedback
Implementing auditing
to evaluate and provide
feedback on practice
adherence and patient
outcomes
Falls TIPS was
complete with patient
name, proper date, risk
factor and prevention
plan.
Patient fall and fall
related injury rates was
obtained through
hospital quality
department and
monthly report was
provided to clinical
champions.
Patient Surveys
Baseline data collected
regarding what patients
knew about their
personal risk of falling
and their fall prevention
plan. Survey employed
the five-point Likert
response format on the
following:
1. Do I recognize my
fall risks?
2. Am I aware of my
fall prevention plan?
Patient survey results
for pre- and post-
implementation of Fall
TIPS were compared
post-mean 4.5,
p=0.031), and
conception knowledge
of fall prevention (pre
mean 3.7: post 4.4,
p=0.264).
At MMC (Bronx, New
York)
The Mann Whitney U
test results showed
progress from baseline
to post Fall TIPS with
scores; for patients’
perceived ability to
recognize fall risk (pre-
mean 4.0; post 4.6.,
p=0.023) and
knowledge of how to
prevent a fall (pre-mean
3.6; post 4,7. p=0.001).
Protocol
Adherence/Fall
rates/Injury rates
At BWH, mean
adherence was 82% to
fall TIPS protocol.
The mean fall rate was
reduced from 3.28 per
1000 patient-days to
2.80 per 1,000 patient-
days
The mean fall-
associated injury rate
dropped from 1.00 per
1000 patient-days to
0.54 per 1,000 patient-
days
At MMC, according to
the audit the mean
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 34
adherence rate to fall
TIPS protocol was
91%. The mean fall rate
saw a slight increase
from 3.04 to 3.10 per
1,000 patient -days
The mean falls-
associated injury rate
dropped from 0.47 per
1,000 patient-days to
0.31 per 1,000 patient-
days
Fowler, S. B., Reising, S. E. (2021). A Replication Study of Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-
Centered Fall Prevention Toolkit. MEDSURG Nursing, 30(1), 28–34. http://eds.a.ebscohost.com.proxy-
hs.researchport.umd.edu/eds/pdfviewer/pdfviewer?vid=3&sid=5c483b22-5891-41c9-8096-3e9def02a892%40sessionmgr4007
Level III
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
“The primary purpose
of this research was to
replicate a published
study to determine the
suitability of a patient-
centered fall
prevention tool and its
impact on patient
knowledge of fall risk
factors and prevention
interventions, overall
fall rates, and falls
with injury. A
secondary objective
was to evaluate ease of
use of the patient-
centered fall
prevention tool and
the need for
modifications”
Qualitative Study
pre and post intervention
design
Sampling Technique
Four Convenient
samples of 30 patients
each period.
Eligible Participants
Inpatients on a medical
telemetry unit.
Inclusion:
Patients who are alert
and oriented and
speaking English or
Spanish.
Excluded: Patients who
were not alert and
oriented and did not
speak English or
Spanish.
Sample size:
Pre-intervention (N-30)
at 1 month
Intervention:
Intervention in the
study included patients
interviewed pre-
implementation at 1
month and during
implementation at 3,
and 6-months regarding
knowledge of their fall
risk and fall prevention
plan
Intervention Fidelity
Alert and oriented
patients selected by
investigator with
consent for the study
Patients were asked two
Likert-style statements
pre and during
implementation bout
Dependent variables:
The two main
outcomes included
Patients’ knowledge on
Fall risk factors and fall
prevention plan.
Overall fall rates and
Fall with injury rates
Measurement tool
(reliability) time,
procedure:
Patients’ knowledge on
fall risk factors and fall
prevention plan was
measured by the study
team members by
asking 2 questions, (a)
An independent t-test
was employed to
compare pre and post
scores of patient
knowledge of falls risk
and fall prevention
The mean scores of
statements
(a) identify falls risks
increased from 4.13 to
4.6 at 1 month; It
remained unaffected in
month 3 and 6 months
(4.57 and 4.47,
individually
The mean for question
(b) how to prevent a fall
increased from 3.97 to
4.67 at 1 month and
remained unchanged at
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 35
During the intervention
(N-120) at 3 months
and 6 months.
Group Homogeneity
None noted
Power Analysis: No
power analysis was
reported which
increased the risk of
making a Type II error.
the knowledge of fall
risk and fall factors and
prevention plan which
include, (a) I am able to
identify my risk for
falling, (b) I know what
I need to do to prevent
from falling
Nurses updated the
laminated Fall TIPS
poster at the bedside,
patients were assessed
for fall risks using the
MFS, individualized
teaching to patient and
family was done using
the Fall TIPS
prevention tool
Investigators checked
compliance to
documentation on the
poster three time a
week for patient name,
date, risk factor and
prevention plan.
Can you identify the
risk for falls.
(b) Are you aware of
what needs to be done
to prevent a fall?
The 5-point Likert scale
was used as a response
format (1=strongly
disagree and,
5=strongly.
Overall, compliance of
nurses to fall TIPS
protocol was measured
by Fall TIPS audit tool
bi-weekly on the 5 data
points patients
name/bed umber,
current date and time,
verbalization of fall risk
factor and fall
prevention plan.
Fall rates and injury
rates were acquired
from the hospital for
the pre and post
intervention period.
3 and 6 months (4.53
and 4.7, individually
The patient’s
knowledge about falls
at 1, 3 and 6 months
compared to pre-
implementation
(p=0.001-0.05)
The overall fall rate
pre-intervention
reduced from 3.3% to
1.9% post intervention.
Staff adherence to the
Laminated Fall TIPS
was 85%.
Leung, W. Y., Adelman, J., Bates, D. W., Businger, A., Dykes, J. S., Ergai, A., Hurley, A., Katsulis, Z., Khorasani, S., Scanlan,
M., Schenkel, L., Rai, A., & Dykes, P. C. (2017). Validating Fall Prevention Icons to Support Patient-Centered Education. Journal
of Patient Safety. 1-10. doi: 10.1097/PTS.0000000000000354
Level IV
Purpose/
Hypothesis
Design Sample Intervention Outcomes Results
“The objective of this
project was to refine
fall risk and
prevention icons for a
patient-centric bedside
toolkit to promote
patient and nurse
Mixed method
descriptive and
qualitative study, which
involved psychometric
evaluation with pre- and
post-test
Sampling Technique:
Convenient sampling
Accepted participants:
88 patients and 60
nurses from 2 academic
medical centers.
Intervention Protocol:
Patients n=88 and
nurses n=60 from 2
academic medical
centers contributed in 4
iterations of testing to
upgrade 6 fall risk and
Dependent Variable:
Fall risk and prevention
icons for a toolkit at
patient bedside.
Measure:
Content validity-
visualization of Icon
Results:
Content validity index
scores enhanced after
modification of icons.
Icons that depicted
several concepts
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 36
engagement in
accurately assessing
fall risks and
developing a tailored
fall prevention plan”.
Eligible participants
Included 88 patients
who were physically
and cognitively able to
participate.
Nurses n=60 from
oncology and medical
surgical units at BWH
and MMC.
Group Homogeneity:
Demographic
characteristic of
patient’s and nurses
was presented in Table
1, which represents
descriptive statistics.
Power Analysis: No
power analysis was
reported which
increased the risk of
making a Type II error.
10 fall prevention
icons.
The methodological
approach of
determination and
quantification of
content validity was
used.
In individual interviews
participants graded
their satisfaction with
the degree to which
icons signified the
concept on a 4-point
Likert scale, aiding
computation of a
Content Validity Index
(CVI)
Comments and
suggestions were
provided by
participants for
improvement.
Treatment Fidelity:
Successive phases of
iterative icon evaluation
and refinement were
carried out until all
stakeholders agreed on
icon’s validity
After reviewing CVI
scores and feedback,
the research team
discussed with the
illustrator to modify the
ions
refinement process and
outcomes:
In the first iteration
each of the preliminary
6 fall risk and 10 fall
prevention icons was
revised by 16 patients.
The mean CV rating
from 1.7 to 3.8 and both
negative remarks about
the picture for the
research team to
address and made
suggestion
All 16 items were
improved.
Second iteration:
12 patients and 30
nurses rated the 16
improved icons and
second group of 30
patients and 30 nurses
rated those icons that
had been further
improved.
Third iteration:
A slash through the
CVI cell demonstrated
that the improved icons
were regarded
acceptable.
Fourth iteration:
Was vital for 2 risk
icons established on
low CVI rating from
the patients.
The final round
involved testing “forget
to call” and “unsteady
required further
iteration for acceptance.
All 16 concepts were
preserved and were
perfected on the basis
of nurses and patient
response.
Using icons to describe
an accurate and easy to
interpret fall risk
assessment and
intervention plan for
care team members
which includes patient
and family was led to
enhanced adherence
with that plan and
decreased falls.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 37
gait” with 30 extra
patients and 30 extra
nurses.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 38
Appendix B.
Fall TIPS Readiness Implementation Checklist
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 39
Appendix C
The Project Timeline for Fall TIPS Implementation
Strategies and Tactics Dates Individuals or groups
affected
Educational Strategies
Pre-test on fall prevention 9/2/20- 9/10/20 Nurses
Formal education on Fall TIPS 9/11//20-9/18/20 Champions, Nurses,
CNA’s, and
Stakeholders
Train the Trainer 9/20/20 – 12/04/20 Unit Champions
Post-test on fall prevention 10/25/20 – 11/06/20 Nurses
Develop educational material 9/2/20-9/10/20 Unit Staff
Data Strategies
Complete audits and individual
feedback
09/27/20 – 12/05/20 Nurses
Provide data report on unit bulletin
board
Weekly Nurses, CNA’s
Identify barriers and facilitator Weekly Nurses, CNA’s,
Champions
Discourse strategies
One-to-one discussion Weekly Nurses and CNA’s
Remind unit staff on coming events 09/27/21-12/05/20 Nurses and CNA’s
E-Mails 9/11/20-12/04/20 Nurses and CNA’s
Rewards 10/25/20-12/05/20 Nurses and CNA’s
Accountability
Obtain formal Commitments 9/13/20-9/18/20 Champions
Provide Supervision 9/27/20-12/05/20 Nurses and CNA’s
Collaboration and communication
Meetings 09/22/20-12/04/20 Champions, Nurses,
CNA’s, and
Stakeholders
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 40
Appendix D
Written Commitment from champions
Adoption and spread of the innovation – Fall TIPS
Education of patients and family on their fall risks and fall prevention plan
1. Nurse champion
a. Fall TIPS is completed and updated daily with the patient’s name, correct date,
risk factors, and individualized fall prevention plan.
b. Complete audits - FALL TIPS Quality Audit Tool and give individual and group
feedback.
c. Give awareness of the daily falls in the unit.
d. Remind unit staff of upcoming events – Fall Prevention Knowledge Pre-test,
education and training on Fall Prevention and Fall TIPS Toolkit, Fall Prevention
Knowledge Post-test
e. Train the trainer
f. Identify barriers and facilitators
g. One-to-one discussion
h. Peer-to-peer feedback
2. Certified Nursing Assistant
a. Fall TIPS in place, with markers and erasers.
b. Patients have the correct mobility aids in the room such as walkers or cane.
c. Bed alarms and chair alarms are working and kept on.
d. Check the universal precautions are in place – Fall sign on, Yellow socks, yellow
bands.
e. Clearing the clutter in patients’ room.
f. Check Laminated Fall TIPS toolkit is available on admission.
3. Physical and Occupational therapist
Communication to the care team on the mobility related concerns:
a. Appropriate device needed for ambulation.
b. The amount of assistance needed for Activities of Daily Living (ADL).
c. Communicating to health team about the patient’s strength and balance.
d. Educate patients on falls prevention.
4. Housekeepers –
a. Cleaning and disinfecting the Laminated Paper Fall TIPS at bedside upon
discharge.
b. Keeping a clean Fall TIPS ready for use.
c. Clearing clutter and spills as soon as possible.
I agree to serve as a champion, to assist with the training, answer questions, and provide
feedback to the healthcare team on 6 North unit
Name: ____________________________
Signature: ____________________________
Date: ____________________________
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 41
Appendix E
Lesson plan for Fall TIPS Education Session
Learning Objectives Content Outline Method of Instruction Time Spent Method of Evaluation
Stakeholders, champions,
Nurses and CNA’s at the
medical surgical unit will
be knowledgeable on the
evidence base for
engaging patient in the
fall prevention protocol.
• Problem of patient falls
• Fall TIPS Findings: Two-year mixed method study and
Randomized control trial (RCT)
Qualitative results summary
• Fall prevention lessons learned
• The Fall TIPS toolkit
• Bed poster
• Patient engagement
• PowerPoint presentation
10 minutes Discussion of why
patient engagement is
vital in fall prevention
Nurses will be informed
on the information and
illustrations of how to
perform a fall risk
assessment utilizing the
Morse Fall Scale (MFS)
and the fall TIPS protocol
• Evidence-based fall prevention strategies
• Universal Fall Precautions
• Three step fall prevention process
• Conducting fall risk assessment (MFS)
• Completing tailored fall prevention care plan
• Consistently implementing the plan
• PowerPoint presentation
• Discussion
• Demonstration
10 minutes Discussion and
demonstrate of the
accurate use of Morse
Fall Scale
Nurses with an interactive
case study, will be able to
complete the three-step
fall prevention process
using the Fall TIPS
• Accurately performing an MFS assessment
• Interactive case study - completing a 3-step fall prevention process by
utilizing Fall TIPS toolkit.
• PowerPoint presentation
• Return Demonstration
10 minutes Return demonstration
of MFS and the use of
Fall TIPS toolkit
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 42
Appendix F
FPTK 11-item Answer Key
Item’s raw correct score for conversion to 1 or 0 T F
1. Bedside nurses know their patients and are better than a standardized screening scale at identifying patients likely to fall.
F
2. The 3-step fall prevention process is comprised of 1) screening for fall risks, 2) developing a tailored fall prevention plan, 3) completing fall
prevention documentation.
F
3. A 75-year-old male with history of recent falls and osteoporosis is admitted for severe abdominal pain. He is at increased risk for injury
if he falls due to his age.
F
4. A common reason why hospitalized patients fall is that their fall prevention plan is not followed.
T
5. Falls can be prevented in patients who are susceptible to falling because of physiological problems by providing a safe environment;
e.g., clear path to bathroom, room free of clutter, good footwear.
F
6. Patient engagement in fall prevention means that the nurse completes the fall risk assessment and prevention plan, and then teaches the
patient about their personal fall risk factors and prevention plan.
F
7. All hospitals are different; therefore, they should develop their own fall risk assessment forms.
F
8. A fall risk screening scale identifies those patients who are likely to fall because they have one or more physiological problems.
T
9. When nurses communicate with patients about their increased risk for injury if they fall, this improves the likelihood that patients will follow
their personalized fall prevention plan.
T
10. Patients at low risk for falls do not require a fall prevention plan.
F
11. Bed and chair alarms should be activated for all patients who screen positive for being at a high risk of falling.
F
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 43
Appendix G
Fall TIPS Copyright Permission
May 25, 2020
Usha Khandagale
DNP Candidate
University of Maryland
Adventist HealthCare White Oak Medical Center
11890 Healing Way, Silver Spring, MD 20904
www.AdventistWhiteOak.com
Dear Ms. Khandagale:
This letter serves as permission for your use of the Fall TIPS Toolkit in your quality
improvement project on fall prevention on a medical surgical unit as a course requirement for
the Doctor of Nursing Practice. You have permission to use the Fall TIPS (Tailoring
Interventions for Preventions for Patient Safety) toolkit in the form of a laminated poster that
staff complete and post it at the bedside. You will not make any changes to the Fall TIPS
Toolkit (except for adding your institutional logo if desired) without a written permission.
Sincerely,
Patricia C Dykes PhD, MA, RN, FAAN, FACMI
Program Director Research
Center for Patient Safety, Research and Practice
Brigham & Women’s Hospital
Associate Professor
Harvard Medical School
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 44
Appendix H
Laminated Fall TIPS Poster in English
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 45
Appendix I
Fall TIPS Quality Audit Instructions
1) Is the patient’s Fall TIPS report hanging at the bedside? Instructions: Record “Yes” if there is a Fall TIPS poster hanging at the bedside and it is for the correct patient. Record
“No” if there is no Fall TIPS poster hanging at the bedside or if it is for the incorrect
patient (i.e., wrong patient name).
2) Can the patient/family verbalize the patient’s fall risk factors? Instructions: Record “Yes” if the patient/family can verbalize any of the fall risk factors
that are displayed on the Fall TIPS poster. Record “No” if the patient/family cannot
verbalize any of the fall risk factors that are displayed on the Fall TIPS poster.
Record “N/A” if the patient is nonverbal or not alert and oriented, and no family is
present.
3) Can the patient/family verbalize the patient’s personalized fall prevention plan? Instructions: Record “Yes” if the patient/family can verbalize any of the fall prevention
interventions that are displayed on the Fall TIPS poster. Record “No” if the
patient/family cannot verbalize any of the fall prevention interventions that are displayed
on the Fall TIPS poster.
Record “N/A” if the patient is nonverbal or not alert and oriented, and no family is
present.
4) If you answered “No” to any question, did you provide peer-to-peer feedback?
Instructions: Record “Yes” if you followed up with the nurse whose patient you audited.
Record “No” if you did not follow up with the nurse whose patient you audited. Record
“Other” if you would like to share why you did not provide peer-to-peer feedback. **We
have found that the peer-to-peer feedback piece is especially important for
implementation. By following up with the nurse, you can identify if there is a gap in
knowledge or another barrier to Fall TIPS completion that we can address.
IMPLEMENTATION OF A FALL PREVENTION TOOLKIT 46
Appendix J
Fall TIPS Quality Audit Tool
