June 2014
Clarity PSO Learning Series
Topic: Falls Prevention

Preventing falls and related injuries has been an elusive goal for healthcare providers across various settings. While different settings and patients bring unique aspects to each fall situation, commonalities have been identified resulting in a cascade of fall prevention strategies and programs. Despite these efforts, though, falls continue to negatively impact patient outcomes, particularly for the elderly. The Centers for Disease Control states that 1 in 3 adults over the age of 65 fall each year and that falls are the leading cause of injury and death for this age group. The odds of a fall resulting in harm also increases with age. Adults 75 and older are four times more likely to have an injurious fall than those who are 65-74.


Falls are a perennial issue for patients and there are many reasons as to why they occur in healthcare settings. In this edition of the Clarity PSO Learning Series, we explore one of the top activities prior to a fall and offer options to help reduce the risk of falls at your organization.

What We Learned

In a recent review of event data reported by our clients, we identified toileting related activities to be a top activity prior to a fall. This category has long topped the list of activities prior to a fall, and from our analysis, we see that this trend continues as it accounted for 32.69% of the falls events. To better understand the nature and characteristics of falls associated with toileting related activities, we reviewed the top locations and contributing factors to events in this area.


*The event reporting for the falls category in this review were based on data elements from the AHRQ event specific Common Format for falls.


Top Locations

  • Telemetry
  • ED
  • Neuro
  • Renal

Contributing Factors (not in ranking order)

  • Physical Symptoms
    • Confusion
    • Dizziness
    • Weakness
  • Environment
    • IV tubing
    • Cords
    • Compression sleeve tubing
  • Equipment - Bed Alarms
    • Activated, patient already fell
    • Activated, did not alarm
    • Deactivated by patient
    • Not reactivated by staff
    • Bed alarm system only alerts in the room; alarm volume set too low; high sensitivity causing alarm to go off with any movement in the bed
  • Feelings and Attitude of the Patient
    • Patient dignity: staff respectful of patient privacy; nearby but not next to patient and patient falls while getting up
    • "I didn't want to bother the nurses"
    • "I thought I could do this"; "I don't need any help"
    • "You made me nervous with all that help"

Additional Research


A qualitative study by Huey-Ming Tzeng (2010) sought to understand the prevalence of inpatient falls associated with toileting in adult acute care settings. Falls related to toileting represented 45.2% of events over a three year period with a common theme being patients falling on the way from the bed or chair to the bathroom. The suggestion from this study was for nursing interventions to focus on safe patient transfers and movements/activity in patient rooms.  


Although this study is clearly limited by the fact that it was conducted in one community hospital on medical/surgical units and cannot necessarily be generalized across all care settings, the process of determining common themes provides utility for other organizations in identifying strategies and solutions to decrease falls or mitigate those falls that do occur.


In another qualitative study, Oosterveld-Vlug et al. (2014) explored the feeling of dignity in nursing home residents, which has been identified as a contributing factor to falls related to toileting activities. While the study was limited to residents in the Netherlands, the authors did compare their results to existing international studies and found similarities in themes related to dignity across countries. Interesting themes negatively impacting dignity emerged including:

  • Will of others enforced upon them
  • Loss of ability to make own decisions
  • Inadequate coping strategies
  • Illness requiring needed assistance with personal intimate care
  • Having to wait for help
  • Time and attention from nursing staff
  • Atmosphere of hastiness

For residents participating in this study, being treated with attention and respect, being listened to, and being taken seriously were considered aspects of good professional care.


Based on our data analysis and knowledge of falls prevention strategies, we suggest the following recommendations to combat falls associated with toileting related activities:

  • Evaluate processes related to patterns; systems thinking, transitions, communication
  • Review toileting related activities and events for patterns in your organization down to the unit level
  • Pin point events indicating workflow issues in getting to the patient in a timely matter (ex. staffing level, time of day, change of shift, etc.) and work with providers for ideas and solutions
  • Consider identifying high risk/high event patient populations and departments/locations with high fall rates
  • Use FMEA (Failure Modes and Effects Analysis) to highlight potential gaps/fragmentation
  • Consider interventions that may mitigate risk going to/from bathroom and up/down from the toilet (Tzeng, 2010)
  • Recognize that bed alarms are only as effective as their use and do not necessarily prevent falls but alert others that patients may be up without assistance
  • Advise each provider to reassure the patient that he/she is not "bothering" the staff with needs for assistance
  • Address concerns with patients about independence and dignity, if necessary, and create a plan with the patient/family for temporary solutions during transient times of illness or injury; should this be a permanent issue, involve other members of the interdisciplinary team as well as resources to promote quality of life
  • Interview and involve patients/families to better understand their motivations, barriers, concerns, suggestions for compliance; factors may include autonomy, dignity, fear, frustration and being perceived as a "nuisance"
  • Consider having staff in the bathroom at all times with patients who are identified as having the highest risk of falling during toileting; must consider patient privacy/dignity (Oosterveld-Vlug, 2014)
  • Gain frontline feedback for understanding and innovative solutions for fall strategies
As you move forward with your falls prevention strategies, it is important that you take the time to do a thoughtful assessment of your organization and microsystem units to create a plan that is right for each unit and the patients. There needs to be an understanding and evaluation of the complexities related to your high risk populations, the various environments in which their care occurs and your current processes. Keep the basic requirements of the plan at the organization level simple so frontline providers can customize the process to each unit and you can minimize competing priorities. Resources, support and engagement by leadership and staff will assist in improving and sustaining the change. While preventing falls has been a longtime goal for healthcare providers, we are making strides in this area and more assessments and research will only help us continue to improve our patients' safety. 

Tzeng, H. M. (2010). Understanding the prevalence of inpatient falls associated with toileting in adult acute care settings. Journal of Nursing Care Quality, 25(1), 22-30.


Oosterveld-Vlug et al. (2014). Dignity and the factors that influence it according to nursing home residents: A qualitative interview study. Journal of Advanced Nursing, 70(1), 97-106. doi: 10.1111/jan.12171

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This information is provided for informational and educational purposes only and should not be construed as financial, medical and/or legal advice. Specific questions regarding this information should be addressed to local advisors and legal counsel. � 2014 Clarity Group, Inc. All rights reserved.
Clarity PSO , a Division of Clarity Group, Inc., offers healthcare providers the opportunity to participate in patient safety and quality improvement efforts with the federal privilege and confidentiality protections of the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). The Patient Safety Act protections include a privilege against discovery in potential litigation. Any provider licensed to provide healthcare services may participate in this program. Clarity PSO is a federally listed PSO (P0015) with AHRQ.