R E V I E W S & A N A LY S E S Falls Risk Assessment: A Foundational Element of Falls Prevention Programs Michelle Feil, MSN, RN INTRODUCTION Patient Safety Analyst Falls are the leading cause of injury-related death in adults over age 65, with death rates Lea Anne Gardner, PhD, RN Senior Patient Safety Analyst rising sharply over the past decade. One out of three adults over age 65 falls each year, Pennsylvania Patient Safety Authority and adults age 75 or older are four times as likely to suffer an injurious fall as adults age 65 to 74.1 Hospitalization increases this risk due to the interplay of intrinsic falls risk factors (e.g., symptoms of illness, treatment side effects) and extrinsic falls risk fac- tors (e.g., unfamiliar environment, intravenous lines and other attachments).2 ABSTRACT The majority of falls can be attributed to a physiologic cause, with 78% of falls labeled Falls risk assessment is a foundational “anticipated” (i.e., physiological falls that can be predicted in patients exhibiting clini- element of falls prevention programs. cal signs that contribute to increased falls risk), and 8% labeled “unanticipated” (i.e., Many falls risk assessment tools have physiological falls that cannot be predicted before their first occurrence). The remain- been developed to screen for risk fac- ing 14% of falls are labeled “accidental” (i.e., the result of mishaps often attributed to tors most predictive of falls. Studies environmental causes). The differentiation of fall types is important because methods have found that these tools accurately for prediction and prevention differ according to the fall type. Anticipated physiologi- identify patients who will fall or those cal falls can be prevented through screening for falls risk factors, in-depth assessment, who are at high risk of falling with a and implementation of targeted prevention strategies. Accidental falls can be prevented sensitivity and specificity of greater than through environmental controls that seek to provide a safe environment. Unantici- 70%. Pairing risk assessment with func- pated physiological falls are, by their nature, not preventable at first occurrence.3 tional assessment tests and injury risk assessments shows promise of further There is increasing regulatory and reimbursement pressure on hospitals to prevent delineating patients at highest risk of patient falls. In 2002, hospital falls resulting in patient death or serious disability were falls and falls-with-injury events. Initial labeled as serious reportable events by the National Quality Forum (NQF).4 In 2008, screening for falls risk using these tools these serious reportable events were labeled as hospital-acquired conditions (HACs) forms the basis for further risk assess- subject to nonpayment by the Centers for Medicare and Medicaid Services (CMS).5 ment and formulation of a multifactorial And beginning in federal fiscal year 2015, hospitals in the worst-performing quartile in falls prevention plan with interventions terms of national HAC rates will receive a 1% reduction in Medicare payments across targeted to the risk factors identified. In the board for all discharges as part of the Patient Protection and Affordable Care Act.6 2011, the Pennsylvania Patient Safety Considering the growing population of older adults and their increased risk of falls Authority received reports of more than and falls injuries, the cost of falls is expected to grow in terms of both human suffering 32,000 falls. Of these patients who and financial cost to individuals and healthcare providers. CMS has recognized this as fell, 64% were reported to have had a a focus area for improvement as part of the Partnership for Patients (PFP), an initiative falls risk assessment completed, 60% that aims to decrease HACs by 40% by the end of 2013.7 Recognizing that not all falls had been identified as at risk for falling, are preventable, the specific goal related to falls is “to cut the number of preventable and 65% were reported to have had fall injuries in half while maintaining or increasing patients’ mobility.”8 The Pennsylva- prevention strategies in place. While nia Patient Safety Authority is currently partnering with the Hospital and Healthsystem these statistics may reflect a lack of Association of Pennsylvania and 81 hospitals across the state as part of the PFP Hospi- documentation, rather than a deficiency tal Engagement Network (HEN) Falls Reduction and Prevention Collaboration. in practice, evaluation of compliance with best practices with respect to falls FALLS IN PENNSYLVANIA prevention is warranted, beginning with Falls continue to be one of the safety events most frequently reported to the Pennsyl- performance of a falls risk assessment vania Patient Safety Authority.9 In Pennsylvania, the rate of hospital falls with trauma for all patients. (Pa Patient Saf Advis is 0.581 per 1,000 discharges, and this is slightly higher than the national rate of 0.562 2012 Sep;9[3]:73-81). per 1,000 discharges.10 Nationally, patient falls with injuries are estimated to cost $19 Scan this code billion per year in direct medical costs.11 At the level of the individual patient, the aver- with your mobile age increase in facility operational costs for a serious falls injury is $13,316, and the device’s QR average increase in length of stay is 6.27 days.12 Based on these numbers, the additional reader to access operational cost to Pennsylvania hospitals for falls with harm in 2010 is estimated to the Authority's falls prevention toolkit. Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 73 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S have been $15,406,612 and 7,254 days in In 2011, 32,802 patient falls were completed falls risk assessment and falls additional length of stay.* This operational reported. Data from these falls event risk identification. cost does not include additional costs (e.g., reports were analyzed following a three- legal fees, potential lost revenue due to step process. Primary analysis of these RISK ASSESSMENT patient dissatisfaction) that may have been reports revealed 64% (n = 21,117) with Falls risk assessment is a foundational incurred as a result of these falls. completed falls risk assessments, 5.2% element of falls prevention programs. A Between 2008 and 2010, Pennsylvania (n = 1,712) lacking falls risk assessments, number of organizations have developed hospitals reported 135,221 falls, of which and 30.4% (n = 9,973) with a risk assess- evidence-based clinical guidelines for 85.7% (n = 115,884) occurred in inpatient ment status that was unknown. The falls prevention, all of which begin with care areas (e.g., medical-surgical units, criti- 30.4% finding suggests that, at minimum, some form of falls risk assessment.15-22 It is cal care units, inpatient psychiatric units), there was no reported documentation recommended that a falls risk assessment 10.0% (n = 13,538) occurred in care areas that this activity was performed. The be done on admission, upon transfer that provide services to outpatients and subsequent analyses took the lack of docu- from one unit to another, with any status inpatients (e.g., emergency department, mentation into consideration. change, following a fall, and at regular radiology), and 4.3% (n = 5,799) occurred The second analysis focused on the intervals.15,18 In 2005, the Joint Commis- in ancillary departments, labs, or unspeci- percentage of falls events reported for sion required “an initial assessment of fied locations.13 The largest number of patients who were identified as at risk for a patient’s risk of falling, as well as con- inpatient falls (N = 115,884) occurred in a fall. In order to identify patients at risk duct of periodic reassessments to enable general medical-surgical units (38.3%, for falls, risk assessments must have been actions to address potentially increased n = 44,400). Eight other inpatient care areas completed. Therefore, falls event reports risks” as part of what was a new National (e.g., psychiatric units, critical care units, indicating completion of falls risk assess- Patient Safety Goal (NPSG) at that time: rehabilitation units) account for the remain- ments (N = 21,117) were used for this to “reduce the risk of patient harm ing 61.7% (n = 71,484) of inpatient falls.13 analysis. Of these falls events, the analysis resulting from falls.”23 This NPSG was showed that 77.2% (n = 16,302) were upgraded to a standard in 2010, with the FALLS RISK ASSESSMENT IN reported for patients who were identified following two elements of performance: PENNSYLVANIA as at risk for a fall, 18.5% (n = 3,907) “the hospital assesses and manages the were reported for patients identified as patient’s risks for falls,” and “the hospital In a review of falls-related sentinel events not being at risk for a fall, and 4.3% implements interventions to reduce falls (i.e., falls resulting in death or permanent (n = 908) were reported for patients with based on the patient’s assessed risk.”24 loss of function) reported from 2004 to risk statuses labeled as unknown. 2011, the Joint Commission identified a deficiency in assessment (i.e., adequacy, Once a patient is identified as at risk for RISK ASSESSMENT TOOLS timing, or scope of assessment) as the a fall, the next step in a falls program is to Over 400 independent risk factors have number one root cause.14 Authority ana- perform an in-depth assessment of the risk been studied and found to be associated lysts queried the Authority’s Pennsylvania factors identified through screening and with increased incidence of falls.25,26 Patient Safety Reporting System (PA- to implement targeted falls prevention Using a retrospective case-control study PSRS) database for falls events reported strategies. This final analysis evaluated design, researchers have narrowed this during 2011 to evaluate whether or not whether the implementation of preven- long list of potential risk factors to shorter patients who fell had a completed falls tion strategies or protocols differed when lists of key risk factors found to be most risk assessment, were identified at risk for risk assessments were completed and falls significantly associated with falling. These a fall, and had prevention strategies or risks were identified. Three separate analy- risk factors have then been translated into protocols in place. ses were performed. The analyses showed falls risk assessment tools.25,27,28 Other that less than half (44.7%, 14,672 of risk assessment tools have been created 32,802) of the falls event reports indicated by individual facilities as part of quality * Additional costs were calculated using the aver- that all three activities had been imple- improvement efforts based on review of age additional cost per falls with harm ($13,316) mented and documented (i.e., completed the literature and facility-specific informa- multiplied by the Authority’s total number of risk assessment, falls risks identified, and reported falls with harm in 2010 (1,157). The tion from incident reports and medical additional length-of-stay days were calculated falls prevention strategy in place). Table 1 record reviews for falls. The validity of using the average additional length-of-stay days shows the different levels of falls preven- falls risk assessment tools is measured (6.27) multiplied by the Authority’s total num- tion strategy implementation, stratified by in terms of sensitivity and specificity. ber of reported falls with harm in 2010. Page 74 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority Table 1. Prevention Strategy or Protocol Implementation According to Risk Assessment and Risk for Fall as Reported to the Pennsylvania Patient Safety Authority in 2011 PATIENTS WHO FELL PATIENTS WHO FELL WHO WHO HAD A COMPLETED HAD A COMPLETED RISK PREVENTION STRATEGIES ALL PATIENTS WHO RISK ASSESSMENT, ASSESSMENT AND FALLS RISKS OR PROTOCOLS IN PLACE FELL, % (NO.) % (NO.) IDENTIFIED, % (NO.) Yes 65.2 (21,390) 82.2 (17,590) 87.4 (14,672) No 15.0 (4,928) 10.0 (2,148) 9.5 (1,590) Unknown 19.8 (6,484) 7.8 (1,652) 3.1 (519) Total 100 (32,802) 100 (21,390) 100 (16,781) Sensitivity is the ability to correctly iden- assessment tests were evaluated for valid- the 1990s and is in widespread use across tify at-risk patients who do end up falling ity, with results presented according to the United States. It is one of only two (i.e., patients assessed at high risk among the settings in which they were tested. falls risk assessment tools that have been all of the patients who fell). Specificity is Within the acute care setting, five nurs- validated prospectively with sensitivity the ability to correctly identify a patient ing falls risk assessment tools and three and specificity testing in its development not at risk of falling (i.e., patients identi- functional assessment tests were evalu- and in subsequent remote cohorts. The fied at low risk among all those who did ated. The eight tools were found to have other is the STRATIFY tool, which was not fall). sensitivity ranging from 66% to 93% and developed in and is in more common use In a review of the literature from 2001, specificity ranging from 25% to 88%. The across the United Kingdom.30 Perell et al. identified 20 risk assessment authors concluded that several tools exist The Hendrich II Fall Risk Model is methods, including 14 nursing falls that demonstrate moderate-to-good reli- another tool in common use across the risk assessment tools and 6 functional ability and that selection of the tool must United States. It was developed in an assessment tests in use across acute care, be guided by the clinical context and the acute care setting with a diverse patient long-term care, and community settings. identified purpose of the tool (e.g., quick population and has been tested for validity The median sensitivity for the nursing identification of high-risk populations, in other settings on a limited basis. Initial falls risk assessment tools (e.g., Morse Fall reduction of risk through reliable identifi- results suggest superior predictive validity, Scale) was calculated to be 81% (range of cation of remediable risk factors).29 reproducibility, and feasibility for use in 43% to 100%), with a median specific- In a systematic review of 13 falls risk acute care settings as compared with the ity of 75% (range of 44% to 88%). The assessment tools, Oliver et al. identified Morse Fall Scale and the STRATIFY tool.31 median specificity of the functional assess- six risk factors that repeatedly emerged as The Johns Hopkins Fall Risk Assessment ment tests (e.g., Timed Up and Go) was significant in tools with levels of sensitiv- Tool was developed and implemented found to be 85% (range of 77% to 93%), ity and specificity over 70%, though no in 2003 at the Johns Hopkins Hospital. with a median specificity of 78% (range single tool assessed all six factors: history It has been evaluated for content valid- of 38% to 87%). Based on these findings, of falls, gait instability, lower-extremity ity and acceptability for clinical users in Perell et al. advocate the use of existing weakness, altered mental status (e.g., the adult clinical care units where it was tools rather than the development of new agitated confusion, impaired judgment), implemented; however, the authors of the tools, recommending the following crite- altered elimination (e.g., urinary incon- tool acknowledge that further validity and ria for selecting the most appropriate tool tinence, frequency, need for assisted reliability testing is necessary.32 for specific settings: high sensitivity, speci- toileting), and prescription of high-risk ficity, and interrater reliability; similarity medications (i.e., medications associated LIMITATIONS OF FALLS RISK of patient population to ones in which with higher falls risks).30 ASSESSMENT TOOLS the instrument was developed or studied; Table 2 provides a side-by-side comparison written procedures explicitly outlining Most falls risk assessment tools that have of falls risk assessment tools currently in appropriate use of the tool; reasonable been tested for validity have been evalu- use by hospitals in the Pennsylvania PFP time required for administration; and ated within the same patient population HEN Falls Reduction and Prevention established thresholds identifying when for which the tools were designed, so the Collaboration: the Morse Fall Scale, the interventions are necessary.2 accuracy of the tools has not been vali- Hendrich II Fall Risk Model, and the dated across different care settings with In a similar review by Scott et al., nursing Johns Hopkins Fall Risk Assessment Tool. different patient populations.30,33,34 Simple falls risk assessment tools and functional The Morse Fall Scale was developed in Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 75 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 2. Risk Factors Assessed by Falls Risk Assessment Tools in Use by Hospitals Participating in the Pennsylvania Hospital Engagement Network Falls Reduction and Prevention Collaboration HENDRICH II FALL JOHNS HOPKINS FALL RISK FACTORS MORSE FALL SCALE RISK MODEL RISK ASSESSMENT TOOL History of falls √ √ Gait instability √ √ √ Lower-extremity weakness Altered mental status √ √ √ Altered elimination √ √ High-risk medications √ √ Secondary diagnosis √ Ambulatory aid √ √ Intravenous line or heparin lock √ Dizziness or vertigo √ √ Depression √ Male gender √ Advanced age √ Automatic high- or low-risk triggers √ Sensitivity 78% 74.9% Not tested Specificity 83% 73.9% Not tested Note: Sensitivity and specificity data for Morse Fall Scale is from: Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging 1989;8:366-77. Sensitivity and specificity data for Hendrich II Fall Risk Model is from: Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res 2003 Feb;16(1):9-21. Shaded rows indicate the six risk factors frequently found to be significant in risk assessment tools with high levels of sensitivity and specificity, as identified in: Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing 2004 Mar;33(2):122-30. falls risk assessment tools have been found fact that the identification of someone in-depth multifactorial risk assess- to have sensitivity and specificity greater at a high risk of falling may be associated ment and formulation of a plan of than 70%,30 but results can vary greatly with implementation of falls prevention care detailing targeted falls prevention when tested across varying patient popula- measures, even in the absence of a formal interventions.15,17-22,40 tions.34 The use of tools itself has been falls prevention program. Therefore, the called into question based on research rate of patients falling in the high-risk INDIVIDUAL FALLS RISK finding nursing clinical judgment is com- group may appear quite low (i.e., high FACTORS parable to the use of risk assessment tools sensitivity and low specificity) because Falling is a complex phenomenon that in identifying patients at risk to fall,35-38 interventions that successfully prevented results from a combination of risk factors. though the accuracy can vary based on falls were implemented.38 Meta-analyses of individual retrospective nursing role and experience level.35 Though commonly referred to as risk case-control studies have been completed Regardless of the falls risk assessment “assessment” tools, these tools have alter- in order to calculate the relative risk method selected, it has been recom- natively been labeled risk “screening” associated with each risk factor. Table 3 mended that hospitals periodically test for tools.17,22,37 This difference in terminology shows the risk factors associated with the internal validity using a two-by-two table may be important in conveying the pur- highest risk of falling, along with their to evaluate sensitivity and specificity.39 pose of these tools. They are intended to relative risk ratios.41 Beyond the risk fac- Vassallo et al. have cautioned against be used as a consistent and reliable screen- tors included in falls risk assessment or relying on such testing for validity within ing tool for identifying patients at risk of screening tools, these risk factors should the clinical setting. The challenge in falling. They do not take the place of a be evaluated as part of an in-depth multi- evaluating the sensitivity and specificity thorough history and physical assessment. factorial risk assessment. of falls risk assessment methods is the Screening should be followed by an Page 76 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority Table 3. Falls Risk Factors and Associated Relative Risk hypnotics, antidepressants, and benzo- RISK FACTOR MEAN RELATIVE RISK RATIO (RANGE) diazepines.51,52 In addition, falls risk in Muscle weakness 4.4 (1.5-10.3) older adults has been found to increase with the use of cardiac drugs (including History of falls 3.0 (1.7-7.0) diuretics, antihypertensives, and antiar- Gait deficit 2.9 (1.3-5.6) rhythmics) and analgesic drugs (opioid Balance deficit 2.9 (1.6-5.4) and nonopioid), as well as with the use of Use of assistive device 2.6 (1.2-4.6) four or more medications, regardless of Visual deficit 2.5 (1.6-3.5) drug class.53 Arthritis 2.4 (1.9-2.9) The Beers criteria, published by the Impaired activities of daily living 2.3 (1.5-3.1) American Geriatrics Society and recently Depression 2.2 (1.7-2.5) updated in 2012, is a useful guideline Cognitive impairment 1.8 (1.0-2.3) for identifying potentially inappropriate Age 80 or older 1.7 (1.1-2.5) medication use in older adults that con- Source: Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002 tribute to adverse patient outcomes. The May;18(2):141-58. Beers criteria specifically identifies the following drugs to be avoided in patients PROFILE OF THE HOSPITALIZED Cognitive Impairment with a history of falls or fractures: anticon- PATIENT AT RISK TO FALL A clear link between increased falls risk vulsants, antipsychotics, benzodiazepines, and delirium and dementia has been nonbenzodiazepine hypnotics, tricyclic Systematic review of studies involving established, especially when agitation and antidepressants, and selective serotonin risk factors for hospital falls reveals the wandering behaviors are exhibited.38,41,42,45 reuptake inhibitors.54 In an analysis of profile of the patient at greatest risk of However, there is also evidence that falls reported to the Authority in 2006, falling to be someone with a history of decreases in global cognition and cogni- the medications most often mentioned in previous falls, impaired mobility, cognitive tive processing speed also increase falls the reports included anxiolytics (benzodi- impairment, and special toileting needs.42 risk in older adults without delirium azepines) and hypnotics, antidepressants, Advanced age,41,42 medications that act on or dementia.47,48 neuroleptics, opioid analgesics/antago- the central nervous system,42 and depres- nists, and insulin/oral hypoglycemics.55 sion42-44 are also contributors. Toileting The impact of medication on falls risk may History of Falls Studies evaluating the circumstances of be more pronounced in older adults, but History of falling within a 1- to 12-month patient falls in the hospital setting have it affects younger adults as well. Increased period has been evaluated across multiple estimated up to 50% to be associated with falls risk has been found in younger adults studies and found to predict future falls toileting or other elimination concerns ages 25 to 60 who are taking two or more with statistical significance and high (e.g., incontinence, urinary frequency, medications, most notably antihyperten- relative risk. Because of this, it has been diarrhea).2,28,42,49,50 Toileting-related falls sives and cholesterol-lowering drugs.56 In suggested that all falls risk assessments have also been found to increase the risk either age group, the challenge has been begin with screening for a history of falls of fall-related injuries by an odds ratio to separate the effects of the medication within the previous 12-month period.45 (OR) of 2.4.49 from the symptoms of the disease process itself and to evaluate the risks and benefits Advanced Age of treatment versus nontreatment when Impaired Mobility Risk for falls and falls with injury increase attempting to adjust medication regimens Gait speed and stride length decrease in order to minimize risk of falling.57 markedly beginning at age 85 for women with age, with adults age 80 or older being and age 90 for men. Slower gait speed has in the highest-risk group.1,41 Depression been found to significantly correlate with increased falls.46 In patients without a his- Medications Depression and its association with tory of falling, screening for balance and Certain medications have been found to increased falls and falls injury rates has gait problems significantly predicts future have a significant association with falls been studied. Use of antidepressants, falls more than other risk factors.45 in the elderly, including sedatives and especially selective serotonin reuptake inhibitors, has been found to have a strong Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 77 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S association with falls and falls with injury. identified: cognitive impairment, pres- — Select a risk assessment tool that But apart from medication use, symptoms ence of at least two chronic conditions, targets risk factors most predictive of depression, ranging from questionable balance and gait impairment, low body of falls.25 to clinically significant, have been found mass index, female gender, poor vision — Assess and periodically reassess the to be independent predictors of falls43,44 and hearing, multiple falls, dizziness, accuracy of the falls risk assessment and have been included in at least one and use of mechanical restraints.41,63 tool within the clinical setting.17,39 formal falls risk assessment tool.28 Rubenstein and Josephson found that — Evaluate the falls risk assessment tool these risk factors for injurious falls match across different clinical areas with FUNCTIONAL ASSESSMENT TESTS risk factors for falls in general, with the different patient populations.30,33,34 exception of female gender and low body Several simple screening tools have been — Use caution when interpreting valid- mass index, which matches the profile of created to assess functional mobility. The ity of risk assessment tools within patients with osteoporosis who are prone Timed Up and Go test is one such tool the clinical setting (i.e., a tool that to fall-related fractures.41 that requires patients to rise from a chair, identifies patients at risk who do not ambulate three meters, turn, return to the Use of an injury risk assessment algorithm fall may be interpreted as having low chair, and sit. Patients who require more labeled “ABCS” has been recommended as specificity when in fact this may be than 14 seconds to complete this test are part of two falls prevention guidelines.17,22 the result of successful prevention more likely to fall (sensitivity and specificity This algorithm was developed as part of strategies).38 of 87%),58 though debate exists as to the a quality improvement project targeted to — Consider screening patients for falls cutoff that is most sensitive and specific.59 reducing falls with serious injury on med- risk in outpatient areas using history ical-surgical units.64 The letters represent A similar test called the Get Up and Go of falls and a functional assessment risk factors for severe injury: Age ≥ 85, test was originally included as part of the test, such as the Timed Up and Go Bones (e.g., osteoporosis, history of previ- Hendrich II Fall Risk Model but later test.17,18,45 ous fracture, bone metastases, prolonged modified to only include the observation — Provide ongoing education to clini- steroid use), Coagulation (e.g., bleeding of the patient rising from a seated position cal staff on proper use of falls risk disorders, anticoagulation), and Surgery while resting their hands on their thighs. assessment tools.15-22 (i.e., postsurgical patients, especially those Patients who require use of their hands — Measure compliance with per- who had recent limb amputation or major to push up in a single attempt are more formance of risk assessments abdominal or thoracic surgery).17,22 likely to fall than those able to rise without periodically, with the goal of 100% using their hands (OR = 2.16). Those who Application of the ABCS injury risk compliance.17,18,20,22 push up and require multiple attempts algorithm is independent of falls risk assessment. Patients with risk factors — Consider combining falls risk assess- have further increased risk of falling (OR = for injury are at risk for suffering injury ment with injury risk assessment to 4.67). And patients unable to rise have the related to any number of causes other identify patients with the highest risk highest risk of falling (OR = 10.08).28 than falls (e.g., excessive bleeding from of falls with harm.17,22,62,64 Because history of falls and impaired invasive procedures, fractures due to Falls researchers have recommended that mobility carry the highest relative risk of weight-bearing activities that place stress facilities choose from existing tools that falls, screening for these two risk factors is on weakened areas of bone). Combining have been tested for validity;2,27 however, often recommended as a simple and effec- the results of falls risk assessment with the Authority recognizes that some hospi- tive risk assessment method in outpatient injury risk identification is recommended tals may be using facility-designed falls risk areas, where each patient encounter is to help identify and focus heightened assessment tools or tools created through time-limited.17,18,45 awareness on patients at highest risk for modification of existing tools. In this case, falls with serious injury.62 it is suggested that hospital falls preven- INJURY RISK ASSESSMENT tion teams assess the validity of the tool Most falls do not result in injury.1,9,13,41 But RISK REDUCTION STRATEGIES internally, ensuring assessment for risk when they do, older adults are at a much Based on a review of the literature and factors identified in the literature as being higher risk of dying as a result of their evidence-based falls prevention guidelines, most predictive of falls. If validity cannot injuries, with men over 70 and nursing hospitals may consider the following strat- be confirmed, use of evidence-based falls home residents over age 85 having the egies for falls risk assessment: risk assessment tools with established highest mortality rates.60-62 The following validity is suggested. — Screen all patients for risk of falling.15-22 risk factors for injurious falls have been Page 78 Pennsylvania Patient Safety Advisory Vol. 9, No. 3—September 2012 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S CONCLUSION in use by hospitals across Pennsylvania are multifactorial, provided by a multidis- Falls prevention begins with screening participating in the PFP HEN Falls ciplinary team, targeted to common falls for falls risk using a falls risk assessment Reduction and Prevention Collaboration. risk factors for all patients, and tailored to tool. A large number of falls risk assess- The Johns Hopkins Fall Risk Assessment each patient’s specific falls risk factors.40 ment tools have been created for use Tool requires further testing to establish Falls risk assessment is the foundational in hospitals.2 Clinical judgment alone validity.32 The process of falls risk assess- element necessary to establishing a suc- can be equally valid in some settings.35-38 ment does not end with screening for risk cessful falls prevention program. Hospitals However, risk assessment tools offer the through use of these tools. Screening is to must first perform a thorough evaluation advantage of process standardization, a be followed by an in-depth assessment of of their current falls risk assessment pro- key to high reliability.65 There is sufficient each risk factor identified.15,17-22,40 cesses before shifting focus to prevention evidence to support the continued use of Risk assessment alone does not prevent interventions. the Morse Fall Scale and the Hendrich falls. Effective falls prevention interventions II Fall Risk Model, as reported to be NOTES 8. HealthCare.gov: preventing serious fall Mar 12 [cited 2012 Jun 12]. http://www. 1. Centers for Disease Control and Preven- injuries and immobility [website]. [cited jointcommission.org/Sentinel_Event_ tion. Falls among older adults: an overview 2012 June 14]. Washington (DC): US Statistics. [online]. [cited 2011 Sep 21]. http://www. Department of Health and Human 15. Gray-Micelli D. Preventing falls in acute cdc.gov/HomeandrecreationalSafety/ Services. http://www.healthcare.gov/ care. In: Capezuti E, Zwicker D, Mezey M, Falls/adultfalls.html. compare/partnership-for-patients/safety/ et al., eds. Evidence-based geriatric nursing injuries.html. protocols for best practice, 3rd ed. New York: 2. Perell KL, Nelson A, Goldman RL, et al. Fall risk assessment measures: an analytic 9. Pennsylvania Patient Safety Authority. Springer Publishing Company; 2008:161- review. J Gerontol A Biol Sci Med Sci 2001 Annual report 2011 [online]. 2012 98. Also available at http://guideline.gov/ Dec;56(12):M761-6. Apr 30 [cited 2012 Jun 14]. http:// content.aspx?id=12265. patientsafetyauthority.org/PatientSafety 16. Health Care Association of New Jersey. 3. Morse JM, Tylko SJ, Dixon HA. Char- Authority/Documents/FINAL%20 acteristics of the fall-prone patient. 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BMC Healthcare Research and Quality; (MD): Agency for Healthcare Research Geriatr 2007 Jul 4;7(17). 2008 Apr. and Quality. http://www.ahrq.gov/qual/ hroadvice. Vol. 9, No. 3—September 2012 Pennsylvania Patient Safety Advisory Page 81 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 3—September 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. 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