The Falls Toolkit

Presentation Outline

• Background on Falls

• Impetus for Project

• Content of Toolkit

• Examples of website

Prevalence and severity• Falls are the leading cause of death due to

injury for people 65 years and older (NCIPC 2002)

• 75% of nursing home residents expected to fall each year (Rubenstein 1994)

• By 2040 estimate of 500,000 hip fractures per year (Cooper 1992, Brainsky 1997)

• Following a hip fracture 17 to 32% mortality (Kannis et al 2003)

Financial Impact of FallsFrequency Chart: Total Costs for 22 Falls

2

76

32

00

2

4

6

8

Total Cost Per Fall

Freq

uenc

y (#

of

falls

)

Average: $33,785

ImpetusCalendar Year 2003 Safety Reports and Aggregated Events

Submitted to NCPS (N=50,663)

Others53%

(26,804)

Fall Related47%

(23,859)

Impetus

Need for a Falls Toolkit: Results of Survey of Patient Safety Managers

0% 20% 40% 60% 80% 100%

White board or dry erase board for pt assess

Falling stars that identify pt at high risk

List of vendors

Falls flip book

Sample tools such as assessments

Sample fall prevention protocol

Articles on falls prevention

Video on fall prevention

Beta-testing

• NCPS asked 8 facilities and one subject matter expert to review the contents of the toolkit

• The sites found the toolkit to be useful, practical and easy to understand

• Based on the responses, NCPS modified the toolkit by:– Adding additional articles for the annotated reference

list

– Modified the format of the toolkit for ease of use

Contents of Toolkit• Notebook

– Developing a falls program• Assembling interdisciplinary team

• Sample policy

– Interventions • Environmental

• For specific populations

– Measuring success – Annotated bibliography

Included in the Toolkit

• Annotated Reference List

Included in the Toolkit

• Posters, fliers and brochures– Increase awareness– Patient & staff

education

Included in Toolkit

• Buttons and Videos

Included in Toolkit

• CD-ROM– Electronic versions of all print materials– Additional resources

• Technology Assessment Guide

• Education Resource Guide

• Power Point presentations

Educational Resource

Guide

www.patientsafety.gov/fallstoolkit

The Falls Toolkit Website

Distribution Plan

• 2 copies distributed to each Patient Safety Manager

• 3 copies distributed to each Patient Safety Officer

• Materials put on internet and intranet

Using the Falls Toolkit

• Create and improve a comprehensive falls prevention program across the facility

• The Aggregated Review Team for Falls:– Analyze data collected as part of the root cause

analysis– Develop actions and outcome measures

Using the Falls Toolkit

• The Interdisciplinary Falls Team:– Development of an interdisciplinary team for

falls– Implement interventions across the facility that

can reduce falls and fall-related injuries

• Front-line Staff– Implement interventions based on the patient

needs

Contacting the National Center for Patient Safety

Erik Stalhandske, MPP, MHSA

Email: Erik.Stalhandske@med.va.gov

VA National Center for Patient Safety

Phone: (734) 930-5890

www.patientsafety.gov/fallstoolkit

vaww.ncps.med.va.gov/fallstoolkit