Team members Staphanie Poe and Maria Cvach designed a tool to help nurses decrease fall rates throughout the Hospital.

Making Fall Stats Plummet

Sometimes a watchful nurse is all that stands between a patient and a dangerous tumble to the floor. But, until two years ago, nurses here were equipped with only an unreliable fall assessment tool that lacked any evidence to back it up. Even worse, it offered little guidance for reducing risk.

Falls are the sixth leading cause of serious injury and death throughout U.S. hospitals. Since 2005, the Joint Commission has placed fall reduction on its annual list of national patient safety goals. And, as of January 2006, hospitals must have effective fall reduction programs in order to receive accreditation.

“With safety standards rising, we knew we had to improve,” says Maria Cvach assistant director of nursing for clinical standards. “Most importantly, we wanted to do something to significantly affect patient safety.”

Like many nurses, Cvach has seen how a single fall can unleash a chain of events that causes a patient to deteriorate. All it takes, she says, is one broken bone that ultimately contributes to a fatal infection: “Then family members are left wondering if the hospital had prevented the fall, would their mom still be alive?”

Three years ago, Cvach joined a team of Hopkins bedside nurses charged with developing a new fall-prevention protocol. Launched by the Nursing Standards of Care and Clinical Performance Improvement Committees, the team was led by Stephanie Poe, assistant director of nursing for clinical quality, whose job often involves investigating patient falls.

For six months the team examined fall research and tools from other hospitals, hoping to find a better risk-assessment protocol. They wanted something that would fit on one page and that could be completed by hand in less than five minutes. When none of the tools they found worked, they embarked on the time-consuming process of designing their own.

Over the next year, the nurses read more than 100 articles on fall prevention and examined protocols from 15 other hospitals to determine which risk factors were backed by scientific evidence—mobility, for instance—and which were not, such as gender. 

The result is a one-page checklist that takes less than a minute to complete and grades an assortment of risk factors, including medication use and impaired vision, on a numeric scale. Once the points are totaled, nurses have a compact but thorough assessment for predicting a patient’s risk of falling.

Since the tool’s introduction in 2004, falls at Hopkins Hospital have decreased substantially, says quality outcomes coordinator Patty Dawson. Between 2004 and 2006, the number dropped from 2.6 falls per 1,000 patient days to 2.2. Meanwhile, after the team published an article about the tool in the Journal of Nursing Quality in April 2005, an estimated 20 hospitals asked to use it.

“We knew it was an effective tool,” Poe says. “But we never dreamed that so many other organizations would want to use it too.”