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Tailoring Interventions for Patient Safety to Reduce Falls

Credits: None available.


Purpose: Greater than 700,000 safety events related to falls are placed yearly for patients in the hospital in the United States (Katsulis et al., 2016). Preventing patient falls is a top safety priority when admitted into the hospital setting. Health care organizations face financial implications such as non-reimbursement by Medicare and Medicaid for injuries sustained by a fall while in the hospital (Katsulis et al., 2016). Annual expenditure for adverse events related to falls was $34 million in 2019 (Rochon & Salazar, 2019). Fall reduction is priority for health care organizations to ensure patient safety during hospitalizations. The purpose of this evidence-based practice project was to decrease inpatient falls at an academic medical center on a medical-surgical unit by implementing the tailoring interventions for patient safety (TIPS) toolkit (Duckworth et al., 2019; Dykes et al., 2017).

Description: This project used the translational science model, knowledge to action (KTA) to implement this project. Tailoring interventions for patient safety (TIPS) is a three-step fall prevention toolkit to assess patients, create a personalized plan, and consistent follow through with each intervention. Staff education was completed on the TIPS tools along with patient education. A total of 80 observations of patient rooms with direct feedback from staff and patients were performed on a medical-surgical inpatient nursing unit. A sign on the footwall in the patient room as a communication tool that is filled out each shift based on the assessment completed in the patient chart. Patient falls were tracked through post-fall huddle forms and completed incident reports, as well as being reported to unit leadership when they occurred. An interview of the nursing staff and patient were completed post fall as well.

Evaluation/outcome: The results for this study showed a decrease in fall rate of 36.1%. The medical-surgical unit had a decrease in fall rate from 3.06, in the four months prior to implementation to a fall rate of 1.10 in the six months post-implementation. At the same time, the fall with injury rate decreased from a pre-implementation rate of 0.84, to 0.40 post-implementation. This is a 48.3% decrease in falls with injury. The medical-surgical unit observed an increase in compliance with fall communication with patients, documentation of interventions and communication tool, and patient and staff engagement for fall prevention. In conclusion, the TIPS toolkit with the three focus areas improved staff and patient engagement in fall prevention, which decreased overall fall rates, and fall with injury rates in the medical-surgical setting.

Evidence-based references
1. Duckworth, M., Adelman, J., Belategui, K., Feliciano, Z., Jackson, E., Khasnabish, S., Lehman, I.S., Lindros, M.E., Mortimer, H., Ryan, K., Scanlan, M., Spivack, L.B., 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), 2. https://doi.org.proxy.lib.umich.edu/10.2196/10008
2. 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. Joint Commission Journal on Quality & Patient Safety, 43(8), 403-413. https://doi.org/10.1016/j.jcjq.2017.05.002
3. Katsulis, Z., Ergai, A., Leung, W.Y., Schenkel, L., Rai, A., Adelman, J., Benneyan, J., Bates, D.W., & Dykes, P.C. (2016). Iterative user centered design for development of a patient-centered fall prevention toolkit. Applied Ergonomics, 56, 117-126. https://doi.org.proxy.lib.umich.edu/j.apergo.2016.03.011
4. Rochon, R., & Salazar, L. (2019). Partnering with the patient to reduce falls in a medical-surgical unit. International Journal of Safe Patient Handling & Mobility (SPHM), 9(4), 135-142. https://sphmjournal.com/product/partnering-patient-reduce-falls-medical-surgical-unit/


  • Amy Allen, DNP, MSN, CNML, RN, Clinical Nursing Director, Michigan Medicine
  • Marisa Streelman, DNP, RN, CMSRN, NE-BC, Staff Specialist, Michigan Medicine


Credits: None available.

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