December 28, 2010 thebaron18

The Falls Toolkit draws heavily from the VA National Center for Patient Safety (NCPS) toolkit. The toolkit has been modified in a few key ways. The addition of many forms and references has been added to make the complete series more robust.

The Falls Toolkit is designed to be printed as a complete manual comprised of 8 Tabs or sections. The Administrator of the Plan and selected members of the Falls Team will require the entire manual. A key difference of this Toolkit is the ability to print only those Tools, Educational Materials and Tabs designed specifically to meet the needs of the remaining members of the Falls Team. This saves time and money by providing only the information that specific departments require.

Each section of this Toolkit beginning, with the section “Background”, is formatted in the same way for ease of use. The main page will display the basic structure of the Tab being discussed and will display the Tools and Educational Materials as they appear in the full document. Any reference to a Tool or an Educational Piece is highlighted in blue text within the documents themselves and is available in the Falls Library.

*Important – At the beginning of each tab you will see links that allow you to download the text of the document only, OR download the text and all associated Tools and Educational Materials together. Also, all Tools and Educational Materials are available individually in the Falls Library section of the website.

The intent of this toolkit is to provide a complete, user-friendly program to address the issue of falls in the healthcare setting. We hope you will find this tool both valuable and easy to use.

II. Background Information on Falls

Falls among the elderly are an important and timely issue. According to the Centers for Disease Control, National Center for Injury Prevention and Control, Falls are the leading cause of death due to injury for people aged 65 years and older (NCIPC, 2002). Each year, 75% of nursing home residents are expected to fall (Rubenstein, 1994). With 17 to 32% mortality, hip fractures are one of the most serious consequences of falls among the elderly (Kannis, et al. 2003). Studies have estimated that there will be 500,000 hip fractures per year 2040 (Cooper 1992, Brainsky 1997).

The financial impact of falls can be substantial. At a Patient Safety 202 training provided by NCPS, Patient Safety Managers were asked to provide DSS cost information for one of three types of adverse events, one of which was falls. Twenty-two facilities provided information regarding the cost of falls with injury. The average cost of a fall with injury was $33,785, with a range between $180 and $240,000

III. Reason & Method of Development of the Falls Toolkit

In 2003, falls represented nearly 47% of all Safety Reports and aggregated events in the NCPS SPOT database. As of March 2004, falls represented 11% of Root Cause Analyses occurring in calendar year 2003.

Inclusion information on Falls KitsTo confirm the need for the falls toolkit, the Falls Aggregate Review survey of Patient Safety Managers included a question about the toolkit. The question asked what information or resources Patient Safety Managers would like to see included. This information was drawn upon in creating the toolkit.
In an effort to insure the usefulness of the Falls Toolkit, NCPS beta-tested the toolkit among 8 facilities and one subject matter expert. The facilities were asked to review the contents of the toolkit for a month and complete a survey. The facilities found the toolkit useful, practical and easy to understand. Additionally, based on the feedback from the facilities and the subject matter expert, NCPS added articles to the annotated resource list, changed the format of the toolkit and added sections.

IV. Using the Falls Toolkit

The purpose of the Falls Toolkit is to aid facilities in creating and improving comprehensive falls prevention programs. A facility-wide falls team should use the toolkit so that interventions can be coordinated across disciplines and care areas. The Aggregated Review Team for falls can use the toolkit to analyze the data collected as part of the root cause analysis and develop actions and outcome measures to reduce falls and fall-related injuries.

The Falls Toolkit can aid facilities in creating an interdisciplinary falls team for reviewing high fall-risk patients and implement interventions to reduce their risk. (See Falls Team/Choosing the Right People) The team can use the falls toolkit to implement facility-wide interventions to reduce the risk of falls. Front-line care staff can use the toolkit to implement evidence-based interventions based on fall-risk or a patient’s areas of risk.

V. Inside the Falls Toolkit

The Falls Toolkit Notebook

The Falls Tookit has the following sections:

  • Background – General information on falls and fall prevention
  • Distribution Plan – Ideas on how to use the toolkit to implement or build upon a Falls Program
  • Falls Team – How to develop an interdisciplinary falls team
  • Falls Policy – What should be in a comprehensive fall prevention policy and an example policy
  • Interventions – Interventions to reduce the number of falls and the injuries related to falls
  • Measuring Success – Tools to measure the improvement in falls and injuries due to the interventions
  • Resources – Additional articles and resources categorized by topic