Mission Possible – A Community Hospital’s Approach to Fall Prevention

Nursing | Maria Payumo, RN, BSN, CCRN-K| August 16, 2017

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Clinical Practice and Patient Safety Coordinator for Adventist Health Glendale shares AHG’s strategy for fall prevention.

Fall prevention remains one of the most challenging patient safety initiatives in any healthcare setting. Notwithstanding the risk for patient injury or death, a fall with injury is expensive and the estimated average cost is $14,000 (TJC, 2015). Falls and trauma were identified by the Centers for Medicare & Medicaid Services (CMS) as preventable adverse events. CMS will not reimburse hospitals if falls and trauma occurred as a secondary hospital acquired-condition.

The Joint Commission also issued a Sentinel Event Alert (TJC, 2015) to educate health care providers about the significance of addressing this issue in order to prevent and mitigate the risks for patient injury or death. Prevention of falls is complex and multifaceted. Factors such as patients’ complex diagnosis, non-adherent behaviors, and inconsistencies with application of fall prevention tactics can predispose a patient to falls.

Nurses must keep themselves abreast with evidence-based strategies, learn how to analyze data that will help improve performance and quality and integrate acquired knowledge in the clinical practice.

Falls and falls with injury are nursing sensitive indicators, which are measured outcomes that get affected, provided, and/or influenced by nursing personnel of which nursing is not exclusively responsible (National Quality Forum, 2004). Nurses play a vital role in the patient care delivery. Preventing patient harm by instituting measures to prevent falls is imperative to our practice. Nurses must keep themselves abreast with evidence-based strategies, learn how to analyze data that will help improve performance and quality, and integrate acquired knowledge in the clinical practice.

In 2012, Adventist Health Glendale’s Fall Performance Improvement (PI) team was established to identify the gaps in clinical practice, and address the increased falls rate in 2011. The multidisciplinary team involves representatives from nursing, allied health and ancillary departments. The team conducts monthly meetings to review each fall incident, analyze contributing factors, report improvement efforts and identify targeted solutions. Fall data are shared and discussed with frontline staff in various forums to promote transparency and hardwire accountability.

Our Fall Performance Improvement initiatives include standardizing the process of fall risk screening, re-assessment and documentation helped in hardwiring the fall prevention tactics. Additionally, involving and collaborating with key-stakeholders made a significant improvement in compliance, readiness, and engagement with the house-wide initiatives. Ongoing education using teaching tools and visual reminders of the need to adhere to the fall interventions helped increase awareness and engagement among patients, families and frontline staff.

Over the last five years, Adventist Health Glendale has continuously and aggressively sought ways to prevent falls. The combination of best practices and targeted action items resulted in the 2016 lowest fall rate in the history of the hospital.


Brown, S.D., Donaldson, N., Bolton, L.B., & Aydin, C.E. (2010). Nursing-sensitive benchmarks for hospitals to gauge high-reliability performance. Journal for Healthcare Quality, 32 (6). Retrieved from http://c.ymcdn.com/sites/www.calnoc.org/resource/resmgr/imported/Nursing%20Sensitive%20Benchmarks.pdf

Centers for Medicare and Medicaid. (2015). Hospital acquired conditions. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

Collaborative Alliance for Nursing Outcomes. (n.d.) The global quest for practice-based evidence-an introduction to CALNOC. Retrieved from www.secure-calnoc.org/Tutorial%20and%20Public%20Files/CalNOC_Public/Public%20Docs/Introduction_To_CALNOCslides.pdf

Heslop, L., & Lu, S. (2014). Nursing-sensitive indicators: a concept analysis. Journal of Advanced Nursing, 70(11), 2469–2482. http://doi.org/10.1111/jan.12503

The Joint Commission. (2015). Sentinel event alert. 55. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_55.pdf

Maria recently presented a webinar on fall prevention and Adventist Health Glendale’s  approach to reducing falls, hosted by EBSCO Health’s Nursing Reference Center™ Plus. Click the link below to watch the replay and dive deeper into the topic of fall prevention.

Watch the Replay

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Maria Payumo, RN, BSN, CCRN-K
Clinical Practice and Patient Safety Coordinator, Glendale Adventist Medical Center

Maria Payumo, RN, BSN, CCRN-K, is the Clinical Practice and Patient Safety Coordinator at Glendale Adventist Medical Center in Glendale, California. She serves as clinical leader and practice/safety consultant throughout the medical center to ensure evidence-based practices and to create a culture of safety.

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