1. Joe P Tomsic
BSN, MHPA, MN
RN, ARNP, NEA-BC, PMHNP-BC
© Copyright by Joseph Patrick Tomsic, 2012
All Rights Reserved

2. This document should guide healthcare professionals reviewing
their current falls and fall injury prevention program. In no way
does this document contain all possible options for developing a
falls and fall injury prevention program. Do not use this
document as the sole source for developing a falls and fall injury
prevention program. Instead, view it as additional information
for the development of a fall injury prevention program that
matches the complexity of your organization. This presentation
is available for use only with permission from the author. The
conclusions in this outline are based on available research and
represent the opinion of the author. The “Fall Prevention
Intervention Workflow Wheel®” , “Fall Prevention Pillars®” and
“SBAR Fall Prevention Tool®” are available for use with
permission of the author only.

3.  20-years of nursing leadership experience
◦ Board certified nurse executive-advanced and Psychiatric
Mental Health Nurse Practitioner
 United States Air Force, Major, Nurse Corps
◦ Psychiatric Nurse Practitioner
 Education
◦ Master of Nursing, Psychiatric Nurse Practitioner
 University of Washington
◦ Master of Health Policy and Administration
 Washington State University
◦ Bachelor of Science in Nursing
 Seattle Pacific University

4.  Introduction
 Scope of the Issue
 Why Do Patients Fall?
 Sequelae from Falls
 Psychiatric Nurse Practitioner Role
 Interventions
 Fall Prevention Interventions Workflow Wheel
 Medication Interventions
 SBAR
 Risk Identification Scales
 Example documentation of fall risk
 Geriatric Considerations
 Recommendations

5.  Falls rate in hospitals is between 2.2-
17.1 per 1000 patient days
 The healthcare facility rate is three
times higher than the community
 Approximately 15,000 people 65 and
older die from falls each year
 Patient falls result in costs of more
than $20 billion a year

6.  Second only to the medication events
 The leading cause of nonfatal injuries
 Leads to negative outcomes
 Prolongs hospitalization
 Legal liability
 Still searching for an answer….

7.  Individual (intrinsic) factors
◦ Comorbidities
◦ Behavioral disturbance
◦ Agitation
◦ Confusion
◦ Vision problems
◦ Delirium
◦ Muscle weakness
◦ Urinary incontinence
◦ Impaired balance

8.  Environmental (extrinsic) factors
◦ Poor workflow design
◦ Inadequate lighting
◦ Trip hazards
◦ Faulty equipment
◦ Poorly defined processes
◦ Nursing unit design flaws
◦ Staff attitude
◦ Lack of education

9.  Five high risk areas
1) Medications
Antipsychotics
Benzodiazepines
Sedative/hypnotics
Digoxin medications
2) Orthostatic hypotension
3) Poor vision
4) Impaired mobility
5) Unsafe behavior

10. Past history of a fall is the
single best predictor of
future falls
30% to 40% of patients
who fall will do so again…

11.  High risk nursing units
◦ Psychiatric
◦ Oncology
◦ Orthopedic
◦ Neurology
◦ Geriatric units
 Classifications of patient falls
◦ Accidental
◦ Anticipated physiological
◦ Unanticipated physiological

12.  Injuries occur in 15% to 50% of falls
Range: Bruises-minor injuries-severe soft
tissue wounds-Skeletal fractures-Death
 Patient falls account for about 65,000
hip fractures annually
 Falls contribute to a 50% higher
mortality
 Loss of confidence, anxiety and
depression, and PTSD

13.  Approximately 1 in 10 falls will result
in a serious injury
 After adjusting for age
◦ Fall fatality rate in can be up to 49% higher
for men
◦ Women are 67% more likely than men to
have a nonfatal fall injury

14.  The psychiatric liaison consultant has
a growing role in acute care hospitals
 The psychiatric nurse practitioner
(PNP) is uniquely trained to lead
patient fall prevention initiatives.
 PNPs are trained to work with patients
who are confused, agitated, delirious,
demented, non-compliant, and on
sedating medications

15.  When almost all the patients are HRF,
the focus needs to shift from
identification to intervention
 Two goals for a successful strategy
◦ Promotion of nurses’ professional knowledge and
skills in implementing a fall prevention program
◦ Cultivation of nurses’ attitudes in treating patients
as their own families

16.  Effective interventions are part of a
basic universal fall program
◦ Assessment of all patients for risk of falling
◦ A culture of safety
◦ Hospital protocol for those at risk of falling
◦ Enhanced communication of risk of injury from a
fall
◦ Customized interventions for those at risk of injury
from a fall

17.  Hospitals successful at reducing fall
rates
◦ Developed a culture of safety
◦ Used fall-risk assessments
◦ Deployed multifactorial interventions
◦ Conducted post fall follow-up
◦ Involved quality improvement
◦ Integrated risk screening within the electronic
medical record

19.  The causes of falls are multifactorial
◦ Intrinsic risk factors
◦ Extrinsic risk factors linked to the environment
 Workflow redesign is more pressing
than ever
◦ Introduction of new technologies
◦ New treatment methodologies

22.  Withdrawal or reduction of
psychotropic medications
 Delirium avoidance program
 Reducing sedative and hypnotic
medications
 Supplementation with vitamin D
and/or of calcium

23.  SBAR is a form of structured
communication adapted from aviation
and the military
 SBAR acronym
◦ Situation (S; what is the situation?)
◦ Background (B; what is the background
information?)
◦ Assessment (A; what is your assessment of the
situation?)
◦ Recommendations (R; how do you recommend the
problem be resolved?)

24. SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.
Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents
SBAR Hand-off
Introduce yourself to the oncoming shift by name, title, and nursing unit.
Prior to change of shift complete an assessment of fall risk. Provide the oncoming care provider with the patient’s risk factors. If using bedside
reporting include the patient and family in fall risk education.
Situation: [patient] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently [oriented X_], [confused],
[lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain]. Patient with [multiple
comorbidities], [behavioral disturbance], [agitation or confusion], [vision problems], [delirium], [muscle weakness], [urinary incontinence],
[impaired balance]. Physically check bed alarm is on and functioning with ongoing shift.
Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a
history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of
behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded],
[confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number].
Assessment: Patient is not responding to redirection or [state interventions] and has made ___ exits attempts in the past ___ hours. The
patient is at risk due to use of [antipsychotics], [benzodiazepines], [sedative/hypnotics], [digoxin] [orthostatic hypotension], [poor vision],
[impaired mobility], [unsafe behavior]. Patient with behavioral disturbance as evidenced by [agitation], [confusion]. Patient with vision
problems and glasses are [on],[at bedside], [remind family to bring in]. Patient currently be treated for [delirium], [ETOH/Opiate withdrawal].
Ambulation impaired due to [muscle weakness], [impaired balance ]. Provide frequent toileting due to [urinary incontinence], [diarrhea].
Recommendations: Additional orders [Medication change], [1:1 observation], [restraints], [enclosure bed] or [other]. Nursing interventions
[move closer to nursing station], [bed exit alarm], or [other]

25. SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.
Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents
SBAR After a Fall
Introduce yourself to the provider by name, title, and nursing unit.
Provide lifesaving care if the patient is in acute distress or rapidly deteriorating call a code and get help! Complete an assessment (do not move
if injured) and provide the provider with the patient’s condition.
Situation: [patient] fell on [date] at [time]. [he/ she] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently
[oriented X_], [confused], [lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain],
or appears to be in pain as evidenced by [overt signs of pain such as grimacing, moaning, guarding]. Additional items to report: The patient
currently has [chest pain], [difficulty breathing], [numbness], [suspect a c-spine injury] or [other]. Current vital signs (including pulse oximetry)
are [state].
Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a
history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of
behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded],
[confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number].
Assessment: Condition is at [baseline] or [has changed]. The patient [does] or [does not] appear to have an injury. The patient appears to have
sustained a [head injury] as indicated by [overt signs such as cuts, abrasion, bump, or swelling on the head], [visual changes] or [headache] from
the fall. The patient appears to have sustained a [possible fracture] AEB [location of deformity or swelling] or difficulty moving, [LLE, RLE, LUE,
RLE etc.] from the fall. The patient appears to have sustained a [neck injury] AEB [numbness] to [extremity]. The patient has a [bruise],
[scratch], [hematoma], [laceration] [superficial wound] on [location]. The injury appears to be [mild], [moderate], [severe].
Recommendations: recommend [provider assessment], [pain medication], [X-ray], [transfer, emergency room] or [other]. The patient is
requesting [pain medication], [anxiety medication], or [other].

26.  A fall-risk assessment is required to
meet the Joint Commission standards
 Commonly used fall-risk assessments
◦ Morse Fall Scale (MultiCare Health System)
◦ Hendrich Falls Risk Model II
◦ Edmonson Psychiatric Fall Risk Assessment Tool
(Memorial Hospital in Illinois)
◦ The Conley Scale
◦ Tinetti Balance Assessment Tool (Western State Hospital)
◦ The Johns Hopkins Fall Risk Assessment Tool (UW
Medical Center)

27. Risk Factors Edmonson
The Johns Hopkins
Fall Risk Assessment
Tool
The Conley Scale Morse Falls Scale Tinetti
Hendrich II Fall Risk
Model
Psychiatric
Assessment
Risk Assessment
Questions?
No
Yes
(Low Risk if complete
paralysis immobilized,
High risk if history of >
one fall within 6
months or fall during
hospitization)
No
Yes
(IV or IV Access is 25
points)
No No Past Medical History
Age? Yes Yes No No No No
Identifying
Information
Mental Status or
Cognition?
Yes
Yes
(cognition)
Yes
(Orientation,
Agitation, Impaired
Judgement)
Yes
(oriented abulation
ability and limitations)
No
Yes
(confusion,
disorientation,
impulsivity,
depression)
Mental Status
Examination
Altered Elimination? Yes Yes
Yes
(Bathroom in a hurry,
wet or soil self on way
to bathroom, up at
night to use BR)
No No Yes Past Medical History
Medications? Yes Yes No No No
Yes
(antiepileptics,
Benzodiazepines)
Past Medical and
Psychiatric History
Diagnosis? Yes No No Yes No No Multiaxial Diagnosis
Ambulation and
Balance?
Yes
Yes
(mobility)
Yes
(difficulty getting out
of bed or chair, Using
supports, weak)
Yes
(Gait)
Yes
(various maneuvers
that takes 8-10
minutes to complete
and requires training)
Yes
(get and go test)
Mental Status
Examination
Screening for
abnormal movement
and gait
Nutrition? Yes No No No No No
Screening for
depression
Sleep Disturbance? Yes No No No No No
Screening for various
psychiatric diagnosis
depression and
bipolar
History of Falls? Yes Yes
Yes
(last 3-months)
Yes No No Past Medical History

28.  Psychiatric professionals can
accomplish a fall risk assessment with
every intake simply by increasing their
awareness of the items included in a
falls risk assessment
 Example questions
◦ “Have you had any falls in the past 6-months or
during the hospitalization?”
◦ “Are you having any issues going to the bathroom
such as urgency or getting up at night?”

29.  The most common cause of accidental
death amount older adults
 5th leading cause of older adult death
◦ Seniors older than 80 years are most likely
to be injured
 Older adults with mental illness are at
increased risk for both falls and
subsequent fractures

30.  Patients do not generally regain pre-
injury levels of physical functioning
 Seniors with mild Alzheimer's may not
adapt mobility behavior to match
cognitive and physical impairments
 Frontal lobe dysfunction
◦ Disinhibition of behavior
◦ Poor judgment
◦ Movement disorders

31.  Develop a delirium avoidance program
as a key intervention
 Use a risk screening tool but consider
also rank ordering patients by fall risk
◦ Consider a parallel process to rank order
patients by degree of falls risk in addition
to the hospital-wide falls risk assessment
scale

32.  Involve the psychiatric liaison team
◦ Add fall risk screening to psychiatric
intakes
◦ Add fear of falling to the multiaxial
assessment
◦ Review medications for all HRF patients
◦ Develop a process to review all patient
falls within 24-hours

33.  Develop chart audit processes
 Develop realistic training including
role playing and hands-on training
 Track the cost of falls and use this
information to calculate the return on
investment for new equipment, staff
education or items such as electronic
incident reporting

34.  Apply Lean principles to any fall
prevention program
 Incorporate fall prevention
interventions into the nurse’s
workflow
 Implement bedside change of shift
handoff communication
◦ Use standardized communication

35.  Place patients in the High Risk for
Falls (HRF) subgroup on bed alarms or
document the reason why a bed alarm
is not appropriate
◦ Develop a standard algorithm for bed-exit
monitoring
◦ Monitor time from bed-exit alarm to staff
response
 Add bed-exit attempts to the RN to
RN and charge nurse report

36.  Place patients at the “highest” HRF
next to nursing station
 Also consider non-HRF patient rooms
e.g. rooms too far from nursing
station to quickly respond
 Review patient fall data to determine
each unit’s “Fall Safe Zones”
◦ Chart audit results often substantiate safer rooms
◦ Conduct a “Safety Reshuffle” q shift

37.  Track close calls e.g. HRF patient self
ambulates to bathroom
 Develop visual tools
◦ Strategically located
 List “Priority High Risk to Fall“ patients
 Risk for current shift
 Patient on alarms
 Alarm standards
 Patients with communication issues
 More

38.  Develop process to make “Fall Safe
Patient Assignments”
◦ Ensure that nursing assignments are
acuity neutral so nurses have time to
frequently check patients.
◦ Develop process for nursing staff input on
falls risk acuity, falls risk and bed alarm
data to build an overall risk profile for
patients each shift

39.  Develop fall risk hand-off
communication process
◦ Awareness of patients with bed alarms
◦ Nurses share falls risk for the oncoming shift
◦ Standardized interventions for patients at the
highest risk for falling
 Have the charge nurse read the names
of each “Priority High Risk to Fall”,
High Risk to Falls with bed alarm as
part of a 2-minute overview

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