The Pennsylvania Patient Safety Authority provided 83 hospitals participating in the Pennsylvania Hospital Engagement Network (HEN) Falls Reduction and Prevention Collaboration with two tools to evaluate their falls prevention programs: a self-assessment survey and a process measures audit. The survey results revealed two categories of best practices with high levels of full implementation: event reporting and postfall assessment. The three categories of best practices with the lowest levels of full implementation were medication review, communication, and use of sitters. Comparing survey responses with the audit results revealed a noticeable gap between levels of full implementation of best practices reported on the survey and compliance with falls prevention practices observed during the audit. Analyses of survey results and hospital rates of falls with injury identified 35 individual falls prevention practices and/or specific program elements that were associated with lower rates of falls with injury. Assessing level of implementation of best practices in falls prevention, auditing for compliance, and analyzing results in relation to rates of falls with injury can identify significant strengths and weaknesses in current hospital falls prevention programs.
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