| Section | Action Steps | Tool That Supports Action | Who Should Use The Tool |
|---|---|---|---|
| Overview | Enlist support of senior leaders | Word Version [30.6 KB] | Senior manager |
| Section 1 | Are you ready for this change? | ||
| 1.1 | Assess the culture of safety in your hospital | Tool 1A, Hospital Survey on Patient Safety Culture; Word Version [49.85 KB] | All interdisciplinary team members |
| 1.2 | Evaluate current organizational attention to falls | Tool 1B, Stakeholder Analysis; Word Version [30.26 KB] | Implementation Team leader |
| 1.3 | Assess and develop leadership support for the fall prevention program |
Tool 1C, Leadership Support Assessment; Word Version [29.62 KB] Tool 1D, Business Case Form; Word Version [29.16 KB] |
Implementation Team leader |
| 1.5 | Identify resources that are available and resources that are needed | Tool 1E, Resource Needs Assessment; Word Version [28.99 KB] | Implementation Team leader |
| 1.7 | Assess your progress on completing readiness for change activities | Tool 1F, Organizational Readiness Checklist; Word Version [29.55 KB] | Implementation Team leader |
| Section 2 | How will you manage change? | ||
| 2.1 | Identify your Implementation Team | Tool 2A, Interdisciplinary Team; Word Version [40.94 KB] | Implementation Team leader |
| 2.2 | Assess the current status of fall prevention activities in your hospital |
Tool 2B, Quality Improvement Process; Word Version [30.48 KB] Tool 2C, Current Process Analysis; Word Version [30.33 KB] Tool 2D, Assessing Current Fall Prevention Policies and Practices; Word Version [33.9 KB] |
Implementation Team leader, individuals designated by the Implementation Team leader |
| Determine staff knowledge about fall prevention | Tool 2E, Fall Knowledge Test; Word Version [32.79 KB] | Staff nurses and nursing assistants | |
| 2.3 | Set goals for improvement based on outcomes and processes | Tool 2F, Action Plan; Word Version [34.66 KB] | Implementation Team leader with quality improvement/safety/risk manager |
| 2.4 | Assess your progress on completing the managing change activities | Tool 2G, Managing Change Checklist; Word Version [29.25 KB] | Implementation Team leader |
| Section 3 | Which fall prevention practices do you want to use? | ||
| 3.1 | Identify how fall prevention care processes connect to one another | Tool 3A, Master Clinical Pathway for Inpatient Falls; Word Version [61.8 KB] | Quality improvement/safety/risk manager, staff nurses, nursing assistants |
| 3.2 | Implement universal fall precautions |
Tool 3B, Scheduled Rounding Protocol; Word Version [29.92 KB] Tool 3C, Tool Covering Environmental Safety at the Bedside; Word Version [36.01 KB] Tool 3D, Hazard Report Form; Word Version [30.13 KB] Tool 3E, Clinical Pathway for Safe Patient Handling; Word Version [61.22 KB] |
Unit manager, staff nurses, nursing assistants, facility engineer, hospital employee who enters patient rooms |
| 3.3 | Identify important risk factors for falls in your patients |
Tool 3F, Orthostatic Vital Sign Measurement; Word Version [32.37 KB] Tool 3G, STRATIFY Scale for Identifying Fall Risk Factors; Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors; |
Staff nurses, pharmacist, nursing assistants |
| 3.4 | Use identified fall risk factors to implement fall prevention care planning | Tool 3J, Delirium Evaluation Bundle: Digit Span, Short Portable Mental Status Questionnaire, and Confusion Assessment Method; Tool 3K, Algorithm for Mobilizing Patients; Word Version [96.08 KB] Tool 3L, Patient and Family Education; Word Version [29.6 KB] Tool 3M, Sample Care Plan; Word Version [32.47 KB] |
Educators, staff nurses, physicians, nurse practitioners, physician assistants, nursing assistants |
| 3.5 | Assess and manage patients after a fall |
Tool 3N, Postfall Assessment, Clinical Review; Word Version [33.64 KB] Tool 3O, Postfall Assessment for Root Cause Analysis; Word Version [43.48 KB] |
Staff nurses and physicians |
| 3.8 | Assess your progress on completing the best practices activities | Tool 3P, Best Practices Checklist; Word Version [29.23 KB] | Implementation Team Leader |
| Section 4 | How do you implement the fall prevention program in your organization? | ||
| 4.1 | Assign staff roles and responsibilities for tasks identified in set of best practices |
Tool 4A, Assigning Responsibilities for Using Best Practices; Word Version [29.14 KB] Tool 4B, Staff Roles; Word Version [31 KB] |
Implementation Team Leader, Unit manager |
| 4.3 | Assess current staff education practices and facilitate integration of new knowledge on fall prevention into existing or new practices | Tool 4C, Assessing Staff Education and Training; Word Version [30.88 KB] | Implementation Team Leader |
| 4.4 | Assess your progress on implementing best practices activities | Tool 4D, Implementing Best Practices Checklist; Word Version [29.22 KB] | Implementation Team Leader |
| Section 5 | How do you measure fall rates and fall prevention practices? | ||
| 5.1 | Collect the right data to learn about falls, fall-related injuries, and their causes | Tool 5A, Information To Include in Incident Reports; Word Version [30.61 KB] | Quality improvement/risk manager, information systems staff |
| 5.2 | Measure fall prevention practices | Tool 5B, Assessing Fall Prevention Care Processes; Word Version [41.74 KB] | Unit manager and unit champions |
| 5.3 | Assess your progress on measuring progress activities | Tool 5C, Measuring Progress Checklist; Word Version [29 KB] | Implementation Team Leader |
| Section 6 | How do you sustain an effective fall prevention program? | ||
| 6.3 | Identify factors need to sustain your fall prevention efforts | Tool 6A, Sustainability Tool; Word Version [32.85 KB] | Implementation Team Leader |
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Preventing Falls in Hospitals
Roadmap
Table of Contents
- Preventing Falls in Hospitals
- Roadmap
- Acknowledgments
- Overview
- Icons
- 1. Are you ready for this change?
- 2. How will you manage change?
- 3. Which fall prevention practices do you want to use?
- 4. How do you implement the fall prevention program in your organization?
- 5. How do you measure fall rates and fall prevention practices?
- 6. How do you sustain an effective fall prevention program?
- 7. Tools and Resources
- Appendix: Bibliography of Studies Implementing Fall Prevention Practices
- References
Publication: 13-0015-EF
Page last reviewed January 2013
Page originally created January 2013
Internet Citation: Roadmap. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/roadmap.html
