VHA National Center for Patient Safety

Falls Toolkit

Fall prevention is an important and timely issue. As of March 2015, falls represented the number one category of root cause analyses submitted to the NCPS Patient Safety Information System, an internal, confidential, non-punitive reporting system.

Falls were the second highest category of sentinel events report to the Joint Commission in 2017.

NCPS staff members worked with the Patient Safety Center of Inquiry, Tampa, Fla., and others to develop the Falls Toolkit.

The Toolkit is designed to aid facilities in developing a comprehensive falls prevention program.

We have made the Toolkit available for a number of years, begining in 2004. The current editon, with updates and revisions, was posted in July 2014.

We appreciate feedback on this effort and the materials offered. If you would like to provide us with suggestions for improving the Toolkit or pass on stories as to how you used this information to improve the falls prevention program at your facility, please contact us: NCPS@va.gov.

VISN 8 has also created a Hip Protector Implementation Kit to help you on your journey to decrease falls. 

Don't Miss Anything

The Toolkit consists of a wide variety of items, please ensure that you scroll to the bottom of this page to view all the resources we have provided.  

Falls Notebook 

Post Falls Huddle

• Falls Decision Tree
• Falls Decision Tree Typology
• Post-Fall Huddle/After Action Review 
• Case Study Number 1
• Case Study Number 2

Products

Injurious Fall Prevention Organizational Self-Assessment Questionnaire

Fall Program Interventions Self-Assessment

The purpose of these questionnaires is to determine the implementation level of key fall injury program attributes within your hospital and inpatient units. By completing these surveys, organizations seek information from administrative, advanced practice and direct care staff who currently practice in inpatient units.

The objectives of this survey are to:

• Determine the level of implementation of fall and injury prevention attributes at organizational and unit level within your hospital and within VISN 8
• Identify opportunities for fall injury program development and expansion as part of your strategic planning
• Implement a learning community among your staff to assist with program implementation,
  spread and sustainability

Once you have completed reviewing these tools and would like further guidance and support please contact ncps@va.gov for assistance. 

Falls Reduction Podcasts

Pat Quigley and Julia Neily discuss various aspects of VA’s position on falls prevention in these two podcasts.

In the first one, two questions are answered:

• Can Nurses alone effectively prevent falls?
• Why has the VA focused primarily on protection from fall Injuries rather than falls? 
• Listen to this podcast  

In the second, another two questions are addressed:

• Can all falls be prevented?
• If practice could be changed tomorrow, what four changes would you suggest?
• Listen to this podcast 
  

Julia Neily is Associate Director, VA NCPS Field Office, and has been involved in many quality improvement initiatives.  

Julia has authored or coauthored numerous articles on a wide range of patient safety issues, given conference presentations, and recently worked together to revise and update the Falls Toolkit.

Additional Information

The VISN 8 Patient Safety Center of Inquiry website offers a wide range of material on falls prevention.

The Home Based Primary Care Fall Prevention and Management Toolkit's primary goal is to share validated fall risk assessment screening tool options with HBPC staff.

Among the material is a brochure, Risk Factors Associated with Falling and What to Do When You Fall, provided as a guide for patients on blood thinners and the risks associated with falls.

The CDC “STEADI Program” *† also provides an array of patient educational materials, which VA clinics can incorporate into their patient education programs. The material is in the public domain and some of it is available in multiple languages.

Implementation Guide for Fall Injury Reduction

Balance Assessment Handbook

• Balance Assessment Products

Osteoporosis Overview

A 13-minute video on osteoporosis is also available and was prepared by the VISN 8 Patient Safety Center of Inquiry, funded by Merck & Co, Inc., and produced by the University of South Florida Health Media Center.

The approach is unique, as it has a special focus on men, unlike many osteoporosis educational materials. It’s designed to teach men about osteoporosis risks, prevention and diagnosis.

• Click here to view the video, “Osteoporosis Occurs in Men, Too.”
• The video is not closed captioned. Here is a transcript.

Enviromental Assessment

Preventing Harm from Injuries from Falls and Immobility - A publication from the Health Research & Educational Trust.

 

Tools

at_risk.pdf File Size: 95KB Printed Size: 8.5 x 11 in Pages: 1	care_poster.pdf File Size: 75KB Printed Size: 11 x 17 in Pages: 1
fall_risk_evals.pdf File Size: 7KB Printed Size: 8.5 x 11 in Pages: 1	timed_up_and_go_test.pdf File Size: 18KB Printed Size: 8.5 X 11 in Pages: 1
morse_falls_pocket_card.pdf File Size: 10KB Printed Size: 3x5 in Pages: 2	hip_protectors.pdf File Size: 93KB Printed Size: 11 x 17 in Pages: 1
hip_pad_brochure.pdf (coming soon) File Size: 88KB Printed Size: 11 x 8.5 in Pages: 2	fall_prevention_at_home.pdf File Size: 229KB Printed Size: 11 x 8.5 in Pages: 2
falls_toolkit_buttons.pdf File Size: 1.6MB Printed Size: 8.5 x 11 in Pages: 1	Blood Thinners: Risk Factors Associated with Falling and What to Do When You Fall File Size: 95KB Printed Size: 11 x 8.5 in Pages: 2

Web Sites

• The Administration on Aging (HHS)*†
• American Association for Retired Persons (AARP)*†
• CDC - National Center for Injury Prevention*†
• CDC - National Center for Injury Prevention: A Toolkit to Prevent Senior Falls*†
• The Gerontological Society of America*†
• The American Geriatrics Society. Clinical Practice Guideline: Prevention of Falls in Older Persons*†
• Practicing Physician Education in Geriatrics Project: Falls Toolkit *†
• National Institute on Aging*†
• 4 Tips Minimize Injuries from Falling as You Age, from Inside Edition*†

• Learn NOT to fall*†

Contact

Thank you for your continued commitment to falls prevention. If you have any questions or would like more information, contact us: NCPS@va.gov 

*By clicking on these links, you will leave the Department of Veterans Affairs Web site.

†VA does not endorse and is not responsible for the content of the linked Web site.

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