Nursing & Care Open Access Journal

Mini Review Open Access

Falls prevention in hospitals-the need for a new

approach an integrative article
Abstract Volume 2 Issue 3 - 2017

Currently, around the world, hospitals invest a considerable amount of effort into
Orly Toren, Michal Lipschuetz
preventing patients’ falls during hospitalization. Despite the intensive emphasis Hadassah medical Organization, Israel
targeted in preventive intervention, reducing the prevalence of this phenomenon
has been limited. At present, hospitals focus on measuring risk of fall rates based on Correspondence: Michal Lipschuetz, Hadassah medical
specific and rigid risk assessment scales which are mainly focused on the assessment Organization, Israel, Email michal.lipschuetz@gmail.com
of the patient’s medical condition, mobility, mental status, toileting, history of falls
and medication therapy. Fall prevention programs are based on the above mentioned Received: February 20, 2017 | Published: March 08, 2017
key factors, which focus on standard safety procedures associated with both patient’s
condition and hospital environment.
The purpose of this article is to describe the current developments on this topic and to
suggest an additional direction of thinking strategy that includes three parts:
i. Engaging the patient into the assessment process to evaluate his/her medical
condition and his/her perception of personal fall risk.
ii. Creating a customized/personalized fall prevention program for patients
susceptible to falls.
iii. Evaluate the patient’s intentions and ability to engage in the required behavior
to prevent falls based on the Prevention program.
This new approach of incorporating all of the three elements may be the basis for
decision-makers on a national and local level to formulate a new hospital policy and
procedures to deal with patients’ falls, on the basis of a comprehensive understanding
of this long-standing concern.

Keywords: patients fall prevention, behavioral intentions, patient participation, risk

fall assessment

Abbreviations: NDNQI, the national database of nursing hemorrhage, bleeding and mortality risks.6 Fall-related injury rate
quality indicators; CDC, center for disease control; US, united states during hospitalization accounts for up to 533 per 1,000 person-years
of America; IOM, the institute of medicine; AHRQ, agency for health for all injuries, 20 per 1,000 person-years for hip fractures, 270 per
research quality 1,000 person-years for head injuries.7
A ‘fall’ is defined as “an unplanned descent to the floor with or
Epidemiology of falls without injury to the patient”.8 The National Database of Nursing
Among adults (65years and over), falls are the leading cause of Quality Indicators (NDNQI) is the largest national database of US
injuries that cause pain, emotional distress and loss of independence, data relating to quality of nursing care.9 Falls in hospitals is one of the
reduced quality of life, increased number of hospitalization days, quality indices measured by the NDNQI organization since 2003 as a
morbidity and mortality.1 It is estimated that by 2025, this group proportion of all falls per 1,000 hospitalization days. The reported fall
of patients will constitute approximately 1.2billion of the world rates range from 1.3 to 8.9 falls/ 1,000 hospitalization days.10,11
population, eighty percent of whom will live in developed countries.2
The lowest rates of falls are reported in Intensive Care Units
The rate of falls among adult’s increases with age, with the prospect
(1.3 per 1,000 hospitalization days), adult wards (3.92 per 1,000
of falls in people aged 65 and older at about 35%, increasing to about
hospitalization days), and the highest rates are reported in rehabilitation
42% for those over 75years of age. Fifteen percent (15%) of patients,
wards (7.3 per hospitalization 1,000 days).12 The main risk factors for
who fall, have a history of falling twice or more a year. Falls are the
falls in hospitalized patients are impaired gait, confusion, urinary
second cause of death in the US (75% of them are elderly people)
incontinence, history of falls and psychotherapeutic medications.13
with the death rate in the United States reaching36.8 per 100,000
people.3 Fall rates in hospitals range from about 30% to 50% or a Economical costs
range of 3.3 to 11.5 falls per 1,000 hospitalization days,4 and they are
the most frequently reported adverse events. Fall-related morbidity The economic burden of falls in general hospitals is significant.
and mortality rates in hospitals are significant. It is estimated that Indeed, it was found that falls increased the cost of hospitalization per
at least 3-20% of the falls have resulted in injury.5 About 30% of patients that have fallen to an average of $6,669, and if the injury was
the hospitalized patients who fall suffer injuries due to the fall, of caused due to a fall, the extra cost is on average between $12,000 to
which 4-6% suffer from severe injuries, including fractures, brain $23,000.14 In 2013, the gross expenditure from falls in the U.S was

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© 2017 Toren et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which
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Falls prevention in hospitals-the need for a new approach an integrative article ©2017 Toren et al. 94

more than $34 billion dollars.15 The CDC estimates that costs related Despite the widespread policy of using scales to identify patients
to falls could increase to $67.7 billion by 2020.3 at high risk of falling, there are major differences among the min
terms of disparate results, diagnostic accuracy as well as a number of
The main components of the additional cost due to falls are extra
problematic methodological issues. All in all, their validity for their
days of hospitalization and the rehabilitation process.14,16,17 Falls and
widespread use is questionable at best since they vary considerably
fall-related injuries in hospitals lead to prolonged hospitalization on
depending on the targeted population and medical environment in
average by 8 days, compared to patients who do not fall; in addition,
which the tool is used. In fact, some of these risk assessment tools
in case of fall-related injuries, the length of stay is extended by 4 more
have been used in different environments than those for which they
days.14
were developed, thus, adjustments have been made to accommodate
Due to these dismal facts, insurance companies in the US have various types of hospital settings, making it difficult to compare
taken a punitive economic policy to reduce the overall phenomenon, results and assess validity. Moreover, significant validity differences
including a non-payment action for inpatient complications. When a were measured between the original authors’ version and those used
similar policy was implemented due to complications from bedsores in practice, resulting in poor fall prediction. The valid scale was
or infections caused by central IV or urinary catheters, there was found to apply mainly to original target populations for which it has
a decrease of 11 % in sepsis and 10 % of urinary tract infections. been developed for. Also there is excessive heterogeneity in terms of
However, this policy did not achieve a significant reduction in falls determining the exact cutoff points for identifying patients at risk for
or injurious falls.18 falls. These considerations highlight controversies and inconsistencies
regarding the widespread use of instruments used in general hospitals.
Falls prevention policy in hospitals No difference in predicting risk for falls was found between the
assessment based on a formal scale and an assessment from a nurse
In light of the health consequences and the economic burden
using her best clinical judgment.21
associated with falls in hospitals, a targeted policy was implemented
focusing on preventive actions. Today’s policy includes activities Fall prevention programs
to identify risk factors and fall prevention interventions.19,20 Special
attention was primarily directed toward identifying and dealing with The common interventions to reduce hospital falls are based on the
two types of risk factors: rationale that measuring the causes of falls and effectively assessing
fall risk factors would help to accurately identify the root causes of the
Factors related to the patient’s medical condition problem. Falls prevention programs in general hospitals are designed
Including old age, anxiety, confusion or disorientation, weakness, to handle both risk factors to falls, associated with the patient’s
impaired gait, urinary incontinence, history of previous falls, impaired clinical condition and the environmental hazards. These programs are
vision or use of certain medications (sleep, tranquilizers, vasodilators, applicable to all patients and consist mainly the nursing staff providing
diuretics, antidepressants, etc.).21 patients’ education, and ensuring that standard safety practices are
in place such as nurse call bell, bedrails, and non-slippery floor in
Factors related to the environment the bathroom, non-slippery shoes, keeping the floor dry, a wet floor
warning and provision of vitamin D supplementation.
Risk Factors at the bedside/ward environment. These factors
include presence/absence of bed side rails, height and stability of any In several numbers of review articles on fall prevention there is
type of seats (including toilet seats) or obstacles such as furniture, no clear and definite evidence for the effectiveness of prevention
power cables, slippery shoes, and an over-equipped patient’s programs in spite of positive evidence indistinct trials; however,
environment.21,22 even these results were not effective to reduce the incidence of falls
over time.25–30 As a result, there have been attempts in recent years
To assess the patient’s fall risk in acute hospital settings, different
to develop smart technologies to detect falls in real time. These
fall risk assessment scales have been developed for prevention
technologies include virtual monitoring of the patient. Information
purposes. These scales are based on some of the factors related to the
based on fall prevention technologies such as virtual monitoring has
patient’s medical condition. The scales that were found to have good
not yet been scientifically proven, and are based mainly on personal
predictive validity for identifying potential falls are the Morse, Stratify
alarms placed on the patient environment which are activated when
and Schmid tools, and these are recommended for use by most health
the patient changes in position, gets out of bed or moves.31
organizations.21,23,24 All scales have one risk category in common:
a history of falls. In addition, each scale includes other categories Patient centered care and fall prevention
that are related to different risk factors contributing to falls. The
Morse scale for example includes risk categories such as” Impaired The Institute of Medicine (IOM) recognizes the centrality of the
gait, Ambulatory aids, Poor orientation to own ability, IV Therapy, patient as a core component to achieve health quality. Patient Centered
Secondary Diagnosis”. The Stratify scale includes the following risk Care is regarded by the IOM as the way to establish a partnership
categories: Impaired mobility, Transfer/mobility, Agitation, Diarrhea/ among practitioners, patients and their families in order to ensure
Help to toilet, Visual Impairment”. their place in the decision-making process with regard to treatment
and taking joint responsibility of the therapeutic process.10 At present,
In all scales, each category gets a numerical value, that are all based on the current hospital strategy to detect fall risk, the patient is
summarized into one score. According to a predetermined cut-off not a partner to any of the risk assessment or the program designed
value, the patient is considered to be at risk or not at risk, based to prevent his fall. As a normal practice, after assessing the patient’s
on the score he/she received from the scale. Some scales have two condition, the nurse determines the level of risk based on the risk
categories (at risk/no risk), while others contain three risk categories assessment scale score and instructs the patient on the precautions to
(low, medium and high). take to prevent falls and injury. In this process, the patient is passive

Citation: Toren O, Lipschuetz M. Falls prevention in hospitals-the need for a new approach an integrative article. Nurse Care Open Acces J. 2017;2(3):93‒96.
DOI: 10.15406/ncoaj.2017.02.00040
 Copyright:
Falls prevention in hospitals-the need for a new approach an integrative article ©2017 Toren et al. 95

at best and does not take any part in the measurement process or process. Using this strategy, the patient is more aware of his risks of
decision-making associated with the desired behavior to prevent the falling and is cognizant of his ability to understand and participate in
fall. For the intervention to be effective there should be an enhanced his or her physical and competence condition.27
partnership between the healthcare team and the patient; moreover,
the patient should be aware of the assessment process, be willing Evaluation of patient’s behavioral intentions
to participate in building the desired intervention so that there is Despite the importance of this issue, there are almost no projects
compliance with the process. to study the concept of patient’s perceptions regarding his physical
condition, and his behavioral intentions based on these perceptions.
The theoretical basis-perceptions leading to It is assumed that the more a patient is involved in understanding his
behavior condition, and the more the staff guides him to express his behavioral
intentions more openly, the easier it would be to implement a
The occurrence of falls is a complex phenomenon. The literature
preventive program tailored individually for each patient based on the
to date suggests that medical professionals are dealing with the
individual’s characteristics and his risk profile. This concept is similar
phenomenon of human behavior using unsuitable approaches. They
to that used for personalized medicine, currently and widely spread
use only rigid parameters to deal with the unpredictability of human
around the globe.34
behavior, while the patient’s perceptions and intentions are kept out
of the assessment and prevention process. Since prevention programs Based on this approach, study by Twibell et al.35 suggested to
practiced today are at most partially effective, it is important to measure the patient’s perception of his condition and his behavioral
include other components, especially those that are related to the intentions to prevent the fall.35 This study was based on the assumption
patient. Using this approach can determine the validity or degree of that preventing falls during hospitalization depends in part on the
objectivity of how a patient views the situation (risk) as a threat to patient’s perception and behavior to prevent falls. The findings suggest
his health, and what are his behavioral intentions–i.e., adhering to the that patients with low intention to request assistance from the staff
prevention plan and refraining to behave in a dangerous way( may to prevent falls perceive little likelihood of falling and are confident
cause a fall ). There are several theories that may explain what leads to perform various actions that may increase the risk of falling. The
people to action: Theory of Reasoned Action/Planned Behavior.32 The study findings support the idea that perception leads to deliberate
theory aims to explain the relationship between attitudes and behaviors behavior. The intention to carry out fall prevention activities is related
within human action. The theory is used to predict how individuals to the perception of the risk of falling, patient’s fear from the fall and
will behave based on their pre-existing attitudes and behavioral the perception of the consequences of falling. In this study, it was
intentions. An individual’s decision to engage in a particular behavior suggested that the staff should take into account the patient’s fear of
is based on the outcomes; the individual’ expectations will come as falling and his intentions to act in accordance with this concern in
a result of engaging in a safe behavior. The main factor affecting the order to construct a customized individual prevention program.
actual behavior is the intention to perform it, and the more serious it
is, the more likely that it will occur. Conclusion
Protection motivation theory Falls and related injuries of hospitalized patients have a
tremendous impact on health and healthcare costs. Despite the great
A person who feels a threat to his health will take action to prevent efforts invested by hospitals to reduce this phenomenon, no success
the damage. Variables associated with the perception of fear are has been made based on the current method of using risk fall scales
the danger of injury, assessment of the risk level and a danger from and building standardized fall prevention programs.
the threat itself.33 Both theories seem to complement each other in
understanding the phenomenon of falls prevention from the view Patient participation in the process of evaluating his/her condition
point of the individual’s voluntary behavior and the individual’s basic is crucial to understand his/her condition and adherence to an effective
motivation to perform an action. treatment. However, this process while necessary is not sufficient.
In addition, it is necessary to assess the perceptions and intentions
The suggested new approach for fall prevention of the patients to effectively evaluate safety behavior during their
Despite the widespread use of fall assessment tools and associated hospitalization.
prevention programs, interventions to reduce falls and their To obtain a reduction of inpatient falls, the healthcare system
consequences are still not entirely successful. All the interventions needs to change its strategy of dealing with this problem today. It is
made so
​​ far are based exclusively on identifying risk of falling by the proposed that instead of the team’s exclusive estimate of the patient’s
nursing and medical staff. Unfortunately, this assessment lacks the condition and of building a general prevention plan, hospitals should
importance of patient participation in the process. As stated earlier, the embrace a broader attitude and effort to deploy a customized approach
purpose of this article is to suggest an innovative approach to deal with for the prevention of falls. This approach should include an estimate
this major problem. Our approach includes the idea of incorporating of the patient’s medical condition, his participation in the assessment
in the process two significant elements. Patient participation in the process in addition to his understanding about his medical condition
process of identifying risk of falling - in recent years, the concept and evaluation of his behavioral intentions. An individualized
of incorporating patient and family into the treatment process and intervention program should be built based on the patient’s specific
decision-making has become more prominent. This approach is characteristics. Although the suggested process of including the
recommended both conceptually and practically by two major patient in evaluating the risk to fall, and the importance of evaluating
organizations AHRQ and IOM.10,30,34 Based on this approach, and on his/her adherence to the prevention plan, extensive research is needed
a limited experience in small nursing homes and community settings, to fully understand its impact, implementation implications and
assessing risk of falling independently by the patient based on his outcomes. Based on the results, a policy that is compatible with this
clinical condition should be incorporated into the risk assessment approach can be formulated.

Citation: Toren O, Lipschuetz M. Falls prevention in hospitals-the need for a new approach an integrative article. Nurse Care Open Acces J. 2017;2(3):93‒96.
DOI: 10.15406/ncoaj.2017.02.00040
 Copyright:
Falls prevention in hospitals-the need for a new approach an integrative article ©2017 Toren et al. 96

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Citation: Toren O, Lipschuetz M. Falls prevention in hospitals-the need for a new approach an integrative article. Nurse Care Open Acces J. 2017;2(3):93‒96.
DOI: 10.15406/ncoaj.2017.02.00040