Preventing Falls in the Hospital Setting

Unintentional falls are the leading cause of injury and injury deaths in adults older than 65 years of age. The medical cost associated with fatal and non-fatal falls in this age group is approximately $50 billion per year. The average cost of an inpatient fall is $62,521.¹ The Joint Commission reported in 2023 that 48 percent of reported sentinel events were related to patient falls.²

What can you do to prevent falls in the hospital setting? The Agency for Healthcare Research and Quality (AHRQ) has identified the following best practices in fall prevention:

• Review what fall prevention practices you use.
• Examine the universal fall precautions you use.
• Conduct a standardized assessment of fall risk factors.
• Identify fall risk factors and incorporate them in the plan of care.
• Assess and manage patients after a fall.
• Conduct a post-fall clinical review and huddle.
• Incorporate these practices into a fall prevention program.³

An effective fall prevention program should include program effectiveness at the organizational level, unit level, and patient level to achieve success.

Data show that inpatient falls or fall-related injuries have improved since the baseline period of 2019 (lower rates are better).

Visit the HSAG HQIC Quality Improvement and Innovation Portal (QIIP) to view your falls data by selecting the “Measure Category” of Other Harms and “Measure” of Inpatient Falls or Fall-Related Injuries.

* Rates are per 1,000 admissions.

Source: Claims data. For additional details on measure specifications, please reference the HSAG HQIC Compendium of Measures. The baseline time period is 01/01/2019–12/31/2019 and current time period is 02/01/2023–01/31/2024.

AHRQ: Medication Fall Risk Score and Evaluation Tool (Tool 3I)

This tool can be used to identify medication-related risk factors for falls in hospitalized patients. A pharmacist would perform this assessment. Use this tool in conjunction with clinical assessment and a nursing risk scale (see Tool 3H above) to determine if a patient is at risk for falls.

Nursing Shortage Crisis and Burnout

According to the U.S. Bureau of Labor Statistics, nursing is a very stable occupation with low unemployment rates compared to most other professions.⁴ However, it is estimated that by the year 2030, 42 out of 50 states will experience a nursing shortage, which can lead to events such as errors, increased mortality, and hospital closures.⁵ A study of more than 50,000 registered nurses and licensed vocational nurses reported that nurses felt a sense of depletion, emotional exhaustion, fatigue, and burnout a few times per week or everyday.⁶

The Centers for Disease Control and Prevention (CDC) collaborated with national subject matter experts to develop a tool targeting burnout at the facility level with actionable opportunities to decrease burnout. A 29-question Targeted Assessment for Burnout (TAB) Tool was developed. If you are interested in piloting this CDC TAB Tool, please contact Christine Bailey, MSN, RN, CSSGB, Executive Director, HSAG, at cbailey@hsag.com. 

Ensuring Medication for Opioid Use Disorder (MOUD) Treatment Through the Care Continuum

This webinar series provides strategies, interventions, and targeted solutions to ensure Medicare beneficiaries have access to MOUD treatment and facilitate the continuity of care.

Next: June 7, 2024 | 12 noon ET (9 a.m. PT).

Find on-demand quickinar recordings, slides, and podcasts from past HSAG HQIC learning series.

Care Coordination Quickinar Series

Quality and Safety Quickinar Series

References

1. Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report. Sept. 1, 2023. https://www.cdc.gov/mmwr/volumes/72/wr/pdfs/mm7235a1-h.pdf

2. The Joint Commission. Sentinel Event Data CY2023 Annual Summary. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/2024/2024_sentinel-event-_annual-review_published-2024.pdf

3. AHRQ. Module 3: Best Practices in Fall Prevention—Training Guide. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/guide.html

4. U.S. Bureau of Labor Statistics. Registered Nurses. https://www.bls.gov/ooh/healthcare/registered-nurses.htm

5. U.S. Chamber of Commerce. Data Deep Dive: A National Nursing Crisis. https://www.uschamber.com/workforce/nursing-workforce-data-center-a-national-nursing-crisis

6. Martin B, Kaminski-Ozturk K, et.al. Examining the Impact of the COVID-19 Pandemic on Burnout and Stress Among U.S. Nurses. J Nurs Regul. Apr. 14, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10074070/

This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No XS-HQIC-XT-06052024-01