Eliminating Falls

HQI Toolkit

This HQI toolkit will assist hospitals in measuring falls, identifying and engaging key stakeholders, providing harm elimination tools that work, and learning through the success of other hospitals.

This toolkit is divided into five sections, which will open individually by clicking on each green tab below (blue indicates the open tab):

  • What to Measure, listing the outcome and process measures focused upon in this toolkit;
  • Key Improvement Team Members, providing a basic list of who should be involved;
  • Tools that Work, a compilation of proven tools and methods;
  • Success Stories, highlighting the success of hospitals that used the tools within this toolkit; and
  • Additional Resources, websites beyond this toolkit that have proven resourceful.

A link to the toolkit evaluation form is also provided in order to receive feedback.

What to Measure

Refer to the HRET-HEN website “AHA/HRET Comprehensive Data System Encyclopedia of Measures” for the full list of improvement measures and additional information.

  • EOM-FALLS-34: Fall Risk Assessment Completed within 24 Hours of Admission
  • EOM-FALLS-37: Falls With or Without Injury (NSC 4)
  • EOM-FALLS-38: Falls With Injury (Minor or Greater) (NSC 5)

Key Improvement Team Members

There are many people that should have an interest in eliminating falls within a hospital. Provided below is a minimal list of stakeholders who should be required as Team Members.  Additional inclusions at hospital discretion are suggested.

Key Members Role

Executive Sponsor

  • Helps the team prioritize improvement efforts
  • Helps the team navigate organizational bureaucracy
  • Ensures the team has resources to fix problems
  • Makes rounds and meets regularly with members of health care team in the care areas

Clinical and Physician Co-Lead

  • Serves as role model for team activities
  • Meets with team regularly
  • Participates in senior executive partnership meetings
  • Communicates with physician group and clinical leadership as needed
  • Assists with implementation of interventions

Quality Leader

  • Supports team activities
  • Ensures results of activities are shared with staff
  • Assigns project leaders to interventions and tracks progress

Content Specialists

  • Provide their expertise on the harm area to team

Ancillary Department Representation

  • Provide their expertise on the involvement of their service regarding the harm area
  • Obtains ancillary staff feedback to initiatives

Frontline Staff Members

  • Encourages unit staff involvement
  • Obtains staff feedback
  • Manages documentation of activities

Patient/Family Representative

  • Provide the voice of the patient/family
  • Review all patient/family education

Tools that Work

Tools that work are key resources to reduce falls.  Hospitals noticing an increase in falls should focus on the tools with “**”. Hospitals successful in reducing falls but not quite reaching Aim should focus on the additional tools provided.

These example tools have been compiled by HQI staff, and are intended for consideration in hospitals as current practices are evaluated and specific programs are developed. These are examples, not fixed protocols that must be followed, nor are they entirely inclusive or exclusive of all methods of reasonable care that can obtain/produce the same results.


  1. Falls Prevention Medication Review – Pharmacist’s checklist to identify medications which may further adversely influence a patient’s risk for fall.


  1. **Fall Prevention Stop Sign - Visual communication of patient at risk for falls with quick easy reference to toileting schedule, ambulation needs and number of assists required.
  2. Falls Agreement with Patient & Family – Agreement form for patient and family to noting why the patient is at risk and the associated interventions.


  1. Patient Education for fall prevention – Strategies for patients to consider when transition home to continue to keep their environment safe and minimize their fall risk.
  2. What To Do When You Fall at Home - A brochure designed to help patients and families know what to do if a fall occurs in the home.


  1. **Post Fall Huddle – Structured format to capture the factors which may have influenced the patient’s fall.  


  1. **Days Since Last Fall Poster – Poster that includes the top ten evidenced based practices as related to fall prevention as well as the number of days since the last fall.

Success Stories

Additional Resources

AHRQ: Preventing Falls in Hospitals, A Toolkit for Improving Quality of Care
This link provides a comprehensive toolkit regarding fall prevention, including background information, prevention strategies, measurement processes and tools for implementation.

IHI Transforming Care at the Bedside How to Guide -Reducing Patient Injuries from Falls
This link provides a toolkit regarding fall prevention, including background information, risk screen assessment, patient education, standardized and customized prevention strategies as well as tips for using teach back in redesign.

Hourly Rounding Supplement by the Studer Group
Detailed toolkit for hourly rounding – what it is, how to implement, tools for assessment, competencies, tracking data and effectiveness of hourly rounding.  The competency checklist validates staff understanding of the components of purposeful rounding as well as the mangers role for observation and evaluation of staff.

Veterans Administration website for  Fall Prevention Tools
This link provides a comprehensive toolkit regarding fall prevention, including background information, prevention strategies, psychiatric and geriatric population specific strategies for prevention as well as tools to consider for injury reduction.

Webinar: STOP Patient Falls
Cal HEN webinar 2/11/2013
Recording of presentation by Sharp Memorial Hospital on their fall prevention program with a focus on connecting the dots between assessment and intervention, sharing of the fall prevention STOP sign, and the use of SMART goals to support staff engagement.

Evaluate this Toolkit

Your feedback of toolkit is important to HQI. Based upon your input, we can determine which tools to keep, remove, replace, or modify to better meet your needs in harm elimination. We welcome and encourage your engagement in providing feedback by completing a tools evaluation.

Evaluate this toolkit