Falls2.pdf

MILITARY MEDICINE, 185, S2:28, 2020

Implementation of a Multicomponent Fall Prevention Program:
Contracting With Patients for Fall Safety

CPT Arrah L. Bargmann, BSN, RN* ; Maj Stacey M. Brundrett, MSN, RN, AGCNS-BC*

ABSTRACT
INTRODUCTION
Falls during hospitalizations can increase the length and cost of a hospital stay. Review of patient safety reports on a
26-bed medical-surgical telemetry unit revealed that the number of falls went from 6 in 2015 to 12 in 2016. The reports
identified a knowledge gap in the patient population and nursing staff related to high fall risk interventions. A literature
review suggests that patient-staff safety agreements, in combination with proper implementation of Clinical Practice
Guidelines, can successfully increase education and adherence to fall prevention measures and reduce the number of
inpatient falls.

MATERIALS AND METHODS
The objective of this evidence-based practice project was to determine if the implementation of a patient fall safety
agreement in combination with an existing evidence-based fall prevention bundle reduces the number of falls. Based
on the literature review, the unit developed a multicomponent fall prevention program that emphasizes staff and patient
education. The program consists of (1) assessment of the patient’s fall risk using the Johns Hopkins Fall Assessment Tool,
(2) daily patient education on factors contributing to the patient’s fall risk during the shift assessment, (3) an educational
handout on fall risk factors maintained at the bedside, (4) ensuring compliance with implementation of previously existing
fall prevention measures, and (5) a patient fall safety agreement.

RESULTS
During the first 4 months, the fall rate decreased by 55% and staff compliance with interventions for high fall risk
patients increased to 89%. To achieve added compliance, the unit implemented an incentive program, which resulted in
the increased adherence to the fall risk interventions. The unit experienced 87 and 88 consecutive fall-free days, which
was the longest consecutive days since May 2015. This project has reached sustainment and the unit continues to see a
low fall rate, well below the national average for medical-surgical units.

CONCLUSION
One of the largest obstacles to this project was staff and leadership turnover. However, the project found that patient fall
safety agreements facilitate a dialogue among staff and patients as well as encourage patients to take ownership of their
own care. They improve the safety of patients and create a collaborative environment for nurses to conduct safe, quality
patient care.

INTRODUCTION
Falls during hospitalizations are a safety concern, resulting in
added healthcare costs, increased length of stay, and increased
disability rates to name a few. According to the Agency

*Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA-Fort Sam
Houston, TX 78234

Poster presentations at Tri-Service Nursing Research Program Evidence
Based Practice and Research Dissemination Course in 2017, the San Antonio
Military Health System and University Research Forum in 2017, and a
podium presentation at National Association of Clinical Nurse Specialists
Annual Meeting in 2018.

The views expressed herein are those of the authors and do not reflect
the official policy or position of Brooke Army Medical Center, the US
Army Medical Department, the US Army Office of the Surgeon General, the
Department of the Air Force, the Department of the Army or the Department
of Defense or the US Government.

doi:10.1093/milmed/usz411
Published by Oxford University Press on behalf of the Association of

Military Surgeons of the United States 2020. This work is written by (a) US
Government employee(s) and is in the public domain in the US.

for Healthcare Research and Quality, falls are one of the
most often reported incidences during hospitalizations.1 Since
2008, hospitals no longer receive reimbursement for traumatic
injuries following falls that occur during a hospital stay.1

Furthermore, Oliver et al. found in their literature review that
falls “are also associated with increased length of stay, higher
rates of discharge to institutional care, and greater amounts of
health resource use.”2 Therefore, falls sustained in the acute
hospital setting remain a priority for any facility.

This project was conducted on a 26-bed medical-surgical
telemetry unit at a 352-bed Level 1 military trauma center
that cares for both civilian traumas and military beneficiaries.
At the facility, policy defines a fall as “a sudden, unintended
uncontrolled downward displacement of a patient’s body to
the ground or other object. This includes situations where a
patient falls while being assisted by another person.”3 Despite
the Clinical Practice Guidelines already in place, retrospective
reviews of the patient safety reporting (PSR) system and
fall response team data within the facility indicated that the

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Contracting With Patients for Fall Prevention

number of falls on the unit doubled in a year. According to
the facility definition, the number of falls increased from 6
in 2015 (a fall rate of 0.83 per 1,000 patient days) to 12 in
2016 (a fall rate of 1.59 per 1,000 patient days). Although
this rate is less than the national average of 3.92 falls per
1,000 patient days for medical-surgical units,4 the increase in
falls was concerning to both leadership and staff nurses. Of
these falls, approximately 42% (5 of 12) of them resulted in
mild harm. The American Society for Healthcare Risk Man-
agement defines mild harm as “minimal symptoms or loss of
function, or injury limited to additional treatment, monitoring,
and/or increased length of stay.”5 Thus, the fall was associated
with additional cost to the facility and/or caused decline in the
patient’s status.

After further review, the unit practice council (UPC) along
with the unit’s clinical nurse specialist (CNS) discovered
location and circumstances of the falls varied. Four of the
falls occurred in the bathroom and the others occurred during
ambulation or patient changing positions, i.e., reaching for
items or trying to transfer self from bed to chair. Despite
the differences in location and cause of the fall, similarities
among the falls became evident: (1) not all the fall preven-
tion measures were implemented and (2) the patient lacked
understanding of their fall risk and corresponding prevention
measures. It was also noted that at the time, the only edu-
cational guidance provided to patients was in the form of
a brief trifold handout for patients to reference. Therefore,
there were areas for improvement within the fall prevention
program on the unit. This article describes the development,
implementation, outcomes, and challenges of implementing
an enhanced evidence-based fall prevention safety program on
a medical-surgical unit. This project falls under the category
of an evidence-based practice (EBP) project because it inte-
grates clinical expertise with a systematic analysis of current
evidence to guide practice change on the unit to positively
impact patient care.6

METHODS
The Iowa Model7 served as the framework of the EBP project.
Following the Iowa Model’s outline, a review of PSRs, injury
reports, and feedback from nursing staff, floor management,
and the unit’s CNS identified falls as the trigger issue for
the unit. Due to the significant increase in the number of
falls, reducing falls was determined to be a priority for unit
leadership. Then, a team was formed that included the CNS
and members of the UPC. A literature review was conducted
guided by the clinical question: On a medical-surgical unit,
does the implementation of a patient fall safety agreement
in combination with current Clinical Practice Guidelines
for fall prevention reduce the number of falls? The terms
“falls,” “patient education,” “patient safety,” “prevention,”
and “agreement” drove a search in Cumulative Index to
Nursing and Allied Health Literature (CINAHL) and Ovid
MEDLINE databases. The goal was to discover if there

were any additional interventions the unit was not currently
implementing that could affect the unit’s fall rate.

Most of the literature discussed the use of bundled fall
prevention programs suggesting that there is no one inter-
vention that significantly reduces falls in the acute inpatient
setting. For instance, one systematic review, consisting of four
meta-analyses and 19 studies, suggested that multifactorial
fall programs can reduce fall rates in the inpatient population
by up to 30%; however, the optimal bundle of interventions
could not be identified from the systematic review.8 Typical
interventions for fall prevention include fall risk assessment,
yellow wrist bands, nonskid socks, and bed alarms.

In addition to fall prevention interventions, education and
a culture of safety are important for reducing falls. Leone
and Adams9 describe a quality improvement project to pre-
vent falls. Part of their intervention was changing their unit’s
culture of safety, which allowed staff to feel comfortable
reporting falls and unsafe conditions. Staff education is also
important when changing the culture on a unit as well as
implementing anything new; everyone must accomplish the
new process the same way as well as understanding the
purpose for the new process or intervention.

A safety agreement may improve patient education about
falls and adherence with fall interventions. According to one
research study, patient fall safety agreements provided struc-
tured fall education, which may lead to reduction in the degree
of injury following a fall.10 Additionally, Nicolas et al.11 saw
a reduction in their fall rate after implementing a patient fall
safety agreement with their patients and families. Finally, the
Joint Commission Center for Transforming Healthcare: Pre-
venting Falls Targeted Solutions Tool12 (TST) highlights the
importance of a customizable multifactorial approach to fall
prevention that includes the use of safety agreements. The TST
is an evidence-based tool that guides an organization through
a step-by-step process to address patient falls with the goal
of generating customizable solutions to address previously
identified barriers. It utilizes the rapid process improvement
methodology to measure fall rates and identify contributing
factors and implement targeted solutions. This methodology
is a “fact-based, systemic, and data-driven problem-solving
methodology” that includes elements from Lean Six Sigma
and change management methodologies.13 The TST from
the Joint Commission Center for Transforming Healthcare
supports the use of safety agreements to improve call light use,
patient awareness, and patient acknowledgement about their
fall risk during hospitalization. All five of the organizations
that initially participated in the pilot study experienced a 62%
decrease in falls with injury and 35% decrease in their fall
rate.14

Altogether the literature review revealed two common
themes. Regardless of intervention, increased education of
patients and nursing staff and a culture of safety were two
key factors in the reduction of fall rates in hospital settings.
Based on the findings from the literature review and PSR
data, the UPC enhanced the existing fall prevention program

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to emphasize patient education, improved communication,
and a culture of safety.

At all military facilities, policy outlines guidance related
to fall prevention, and it focuses on three components:
assessment using the Johns Hopkins Fall Assessment Tool
(JHFAT),15 nurse-initiated s, and education of the patient
and family. The UPC reviewed the existing fall prevention
bundle, and updated it based on the above literature review.
The pre-project fall prevention bundle included five main
components: (1) assessment utilizing the JHFAT; (2) nurse-
initiated sets; (3) patient and family education; (4) visual
cues such as falling star, falls wheel, and yellow socks; and
(5) other safety measures such as nonskid socks, gait belts,
and bed alarms. Nurse-initiated s are a group of s
in the electronic health record that serve as reminders and a
way to document interventions taken such as bed alarm on,
offering toileting, and remaining with the patient at all times
when they are out of bed for high fall risk patients.

The new fall bundle included the previously existing fall
prevention measures plus (1) daily patient education on factors
contributing to the patient’s fall risk during the shift assess-
ment; (2) a patient educational handout on fall risk factors at
the bedside, which included a modified JHFAT and key fall
safety education points; and (3) a patient fall safety agreement.
Modifications to the JHFAT included removing age and com-
bining all the mobility and cognitive items into one box to
simplify the form, thus easing communication of risk factors
for patients. The modification to the tool was agreed upon
by the UPC members under the guidance of the CNS; it was
simplified for patient understanding. The goal of the abridged
tool was to involve patients in the fall risk assessment. In each
shift, the patient was reassessed and received reinforcement
education of all the fall prevention measures associated with
the patient’s specified fall risk.

The adherence of this EBP bundle was measured by
determining the level of the patient’s fall risk understanding
and associated fall prevention interventions pre- and post-
patient fall safety agreement implementation. Additionally,
staff adherence with pre-existing fall prevention interventions
outlined in accordance with hospital policy pre- and post-
implementation was monitored via audits. In preparation for
the implementation of the bundle, the UPC collected baseline
fall data from the PSR system and created an in-service for
staff members, the patient fall safety agreement, an education
handout, an abbreviated JHFAT sheet, and ambulation status
for the white boards. The fall safety agreement included items
such as the patient has been educated on fall risk prevention
strategies and that they acknowledge falling can cause serious
injuries. Therefore, they agree to ask for help in to
prevent falling.

Implementation of the bundle began in early February
2017 once 90% of the staff received face-to-face in-services,
which outlined the new bundle. The in-service addressed
baseline fall data collected from the PSR system and post-fall
response team reports, the purpose of the project, as well as

explanations and examples of the new forms. The forms
included the patient fall safety agreement, modified JHFAT,
fall prevention information handout, and new signs for the
patient rooms. Copies of the patient education handout, the
modified JHFAT, and fall prevention signs were laminated on
yellow paper and placed on the bedside table or on the white
board at the foot of every patient’s bed, within their line of
sight. Upon completion of the in-service, staff members were
encouraged to sign a pledge to promote a culture of safety and
utilize the tools of the fall prevention bundle.

During the in-services, which occurred during shift change
safety huddles, the staff were instructed to ensure all patients
received the fall prevention education and had a documented
JHFAT and a signed patient fall safety agreement upon admis-
sion or transfer to the unit. Staff members were allowed up to
24 hours to have the bundle implemented if patients arrived
to the unit sleepy postoperatively or with altered mental sta-
tus. Nursing staff were also encouraged to educate family
members especially if the patient was not able to receive
the education upon arrival. Once patients received the fall
risk and prevention education, they were encouraged to sign
the agreement with the nursing staff. Then, the signed safety
agreement was placed in a separate binder that contained
all the patient fall safety agreements for the unit. Then, the
nursing team placed a star by the patient’s name on the charge
nurse census board to serve as a visual cue to the auditors,
nursing staff, and unit leaders that the patient received the
education and signed the agreement. The modified JHFAT was
to be updated by the nurse in the presence of the patient each
shift, hung in the room, and utilized as a communication tool
for nursing staff to see which risk factors contributed to the
patient’s fall risk.

RESULTS
UPC members and unit management conducted audits on
dayshift and nightshift at least three to five times per week to
observe adherence with the unit fall prevention bundle before,
during, and after the project. Pre-implementation auditors
checked to ensure all interventions were in place that corre-
sponded to the patient’s documented fall risk. After project
implementation, auditors were instructed to check the desig-
nated binder for a signed fall agreement as well as review
the patient’s charted fall risk as determined by the bedside
nurse using the JHFAT prior to beginning each audit. The
auditors would then ask the patient if they knew what their
fall risk was: low, moderate, or high. If the patient’s response
did not match the assessment, reeducation was immediately
given using the patient education handout on the patient’s
bedside table or whiteboard. Finally, the auditors would then
visually check rooms to ensure all interventions were in place
based on the patient’s identified fall risk. Inter-rater relia-
bility was not measured. However, for each intervention the
observation was either adherence or not. For instance, the bed
alarm was either on or off for a high-risk patient. Auditors

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received education on each item to examine prior to starting
the audit process. Unit Practice Council members collected
post-implementation surveys that patients received prior to
discharge and compared them to the visual and verbal audits
during the hospital stay. All data from the audits were recorded
on a spreadsheet and then compared to baseline data retro-
spectively from the PSR system and post-fall response team
reports.

The initial audit revealed only 5 (approximately 30%)
of 17 patients identified as high fall risk patients had bed
alarms on and there were 2 recent falls on the unit. Within
the first 2 weeks of implementing the fall bundle, the bed
alarm adherence increased to 71%. Hoping to achieve a bench-
mark of 90%, the UPC instituted an incentivized performance
improvement project known as “Catch ‘em Doing Good.” The
incentive was “Sunshine Fund” dollars, which staff could use
to purchase snacks from the unit’s snack bar. In each shift
the staff were audited on their adherence with all the fall
bundle interventions. Staff earned a star when 100% of the
nursing interventions were in place for all the patients on
their team, the fall safety agreement was signed, and all their
patients demonstrated understanding of their fall risk. With the
addition of the incentive program, adherence with bed alarms
and fall safety agreement rose to 89% after 3 months.

The incorporation of the fall bundle with the patient fall
safety agreement notably increased the percentage of patients
that correctly stated their fall risk and verbalized understand-
ing of what prevention measures correlated with their fall risk.
Implementation of the staff incentive program improved the
culture of safety on the unit and resulted in a profound increase
to 95% of patients correctly stating their fall risk suggesting a
positive correlation with understanding interventions and the
bundle, while seeing a negative correlation with falls. Since
the implementation of the project, the unit’s fall rate decreased
from 1.59 per 1,000 patient bed days for 2016 to 1.38 per
1,000 patient days for 2018 (see Fig. 1). The lowest fall rate
was seen during the second quarter of 2017, which was right
after implementation of the bundle; the fall rate was 0.54 per
1,000 bed days. Additionally, the unit has experienced two of
the longest stretches of fall-free days since May 2015, 87 and
88 days.

As a result of this project, the fall rate and the number
of falls with mild harm have remained low. The unit only
experienced no harm or mild harm events; none of the fall
events were classified as moderate or severe harm or death.
If the patient experiences a slight change in status or requires
limited additional treatment, then the event classifies as mild
harm. If the event resulted in an injury that impacts daily
functioning or quality of life to some degree, then it would
receive a classification of moderate or severe harm.5 Since
the implementation of the project, only three (approximately
37.5%) of the eight falls in 2017 resulted in mild harm (see
Fig. 2). In 2018, 5 (50%) of the 10 falls resulted in mild harm.
However, all five of these were due to a medical event, two
resulted in a code blue and two in a rapid response team

activation; the staff followed all the applicable fall interven-
tions for each of these events. While there was an upward trend
in the number of fall events in 2018, all except one in the third
and fourth quarters of 2018 had the appropriate fall prevention
interventions in place prior to the event. And, overall the
unit has consistently gone longer between fall events. From
mid-February through December 2018, the average number
of days between falls was 35.96 days. Prior to the intervention
(January 2016 to early February 2017), the average number of
days between falls was 27.8.

Age did not seem to play a factor in the falls. In 2016 prior
to the project implementation, patients age 18–49 accounted
for eight (approx. 67%) of the falls. The following year the
ages were more evenly distributed, with each decade account-
ing for one or two falls. In 2018 six (60%) of the falls were
patients between the ages of 50 and 64. However, the medical-
surgical unit that conducted the project admits mostly civilian
traumas and surgical patients.

DISCUSSION
The implementation of a multifactorial fall prevention bundle,
including a patient fall safety agreement and staff incentive
program, served as a pivotal instrument for the fall rate on
the unit and has several implications for nursing. The safety
agreements and patient education handouts provided nurses
with a standardized set of tools to ensure structured education
is provided to each patient on a consistent basis. The signed
patient safety agreements and staff safety pledges also pro-
moted a culture of safety making both patients and nursing
staff responsible for interventions related to fall prevention.
To encourage adherence, the UPC implemented a staff incen-
tive/recognition program known as “Catch ‘em Doing Good”
to increase staff motivation and adherence with fall prevention
policies despite the frequent changes on the unit. Initially,
the incentive program revitalized the project, served as an
effective means of reinforcing components of the bundle,
and increased staff adherence with components of the fall
prevention program. Unfortunately, the audits required to
sustain the incentive program proved to be too much of a
burden to continue in the long term. The benefit of these audits
was to increase the number of personnel asking the patients
about their fall risk status. Therefore, the patients received
reinforcement of their education, which likely contributed to
the early success of the project.

While only one medical-surgical unit in the facility
implemented this bundle, other units and their leadership took
note of its success. After presenting this project in numerous
forums to the Facility Nurse Practice Council and local and
national conferences, parts of this bundle were incorporated
into the facility policy. Staff members educated other units
about the lessons learned throughout this project as other units
began to adopt parts of it prior to the facility officially updating
the fall policy. Leadership agreed that the most effective
component of the project was the fall safety agreement since it

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FIGURE 1. Quarterly Falls Rate.

FIGURE 2. Falls by Definition.

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encouraged a dialogue between the staff and the patient. Plus,
it enabled the patient to be an active participant in their care.

Like most projects the implementation of the bundle was
not without its challenges. For the first 4 months, the unit
showed a positive trend in the fall rate. However, with staff
turnovers and complacency, the rate began to increase at the
beginning of 2018. Leadership did a push, re-engaging with
the staff at shift change huddles to re-energize the program
(annotated by an ∗ in Fig. 1). At that time, there was also
a decrease in the adjusted fall rate, which does not include
assisted falls. Assisted falls occur when the staff is in the room
with the patient and all the appropriate interventions are in
place. The staff are with the patient when they begin to fall
and assist them to a seated position on the floor. The facility’s
definition of a fall still includes these events as a fall. However,
in these instances the staff probably prevented mild or even
moderate harm since they were with the patient and eased
them to the floor; they implemented all the appropriate fall
interventions.

Military facilities are unique in that floor management
and staff change frequently. For instance, during the first
11 months of the project, the head nurse changed twice, 9
staff members (approx. 32% of the military staff) received rou-
tine military reassignments, and 15 (approx. 28%) additional
nursing staff were oriented to the unit. This created a need for
continuous reinforcement of the bundle components to ensure
all staff members were aware of the unit’s fall prevention
program and safety agreement. Additionally, medical-surgical
units are staffed with nurses with less experience. Using
Benner’s Model,16 the majority (approximately 65%) of the
staff would be considered advanced beginners. Therefore, the
experience level on the unit is low. On a shift there are a mix
of between 7 and 10 registered nurses and licensed vocational
nurses, including the charge nurse. Of those, at least four or
five have less than 2 years of nursing experience. Military
charge nurses typically have about 2 years of experience,
while civilian charge nurses could have anywhere from 3 to
over 10 years.

More studies and research are needed to further evaluate
the sustainability and efficacy of multifactorial fall prevention
programs with safety agreements in both military and civilian
healthcare facilities. Additionally, the optimal bundle of fall
prevention interventions has yet to be identified. It would
be helpful for future studies to determine the interventions
best suited to prevent falls in the medical-surgical setting, the
essential elements of a patient education program, and specific
factors appropriate to increase a culture of patient safety for
fall prevention.

CONCLUSION
Despite the limitations and challenges previously discussed,
since implementation the unit has seen (1) decreased
frequency of falls; (2) less total falls per given time; (3)
maintained low fall rate per 1,000 patient days, and (4) a

maintained low number of falls with mild harm. While falls are
concerning, the unit started with a rate well below the national
average. Therefore, any improvement is difficult to achieve.
The unit also experienced 87 and 88 consecutive fall-free days
which were the longest consecutive number of days since May
2015. Effective education and adherence with fall prevention
measures in both nursing staff and patient populations were
a vital component of fall prevention and increased patient
safety. Safety agreements and bundled prevention approaches
facilitate a dialogue among staff and patients. It improves the
safety of patients, and it creates a collaborative environment
for nurses to conduct safe, quality patient care.

ACKNOWLEDGMENTS
The authors acknowledge the effort of the staff and unit leadership who
helped during the implementation of the project. Special thanks to Tri-Service
Nursing Research Program for their assistance in the publication process. The
authors also declare that the evidence-based project was not funded by any
agency or organization.

REFERENCES
1. Agency for Healthcare Research and Quality: Preventing Falls in Hos-

pitals: A Toolkit for Improving Quality of Care. Rockville, MD, U.S.
Department of Health and Human …