Recognizing Fall Prevention Week

Fall Prevention Awareness Week started Saturday, September 22 and runs until Friday, September 28. has excellent resources and tools to support ongoing efforts including flyers, posters, fact sheets and videos. A fall can result in injury, trauma and even death. Sometimes the fall isn’t even the scariest part and it is the post-fall events of surgery, immobility and potentially pneumonia that result in death.

Like many baby-boomers, my mother is the caretaker for my grandmother. Now in her 90s, my grandmother is sharp as a tack, witty, and full of life, however, she is also very frail and purposeful in her movements. My mother lives in a two-story Cape-style home and serves dinner in her dining room, requiring my grandmother to venture down a flight of stairs from her bedroom. My mother’s husband has a coordinated drill with my grandmother that I always enjoy watching when I’m around. He takes her arm gently in his, stands beside her and they descend slowly and methodically down the stairs, one at a time, as if they were a single person. He matches his stride to hers, paying close attention to her hesitations, much like a dance partner. While he initially started doing the “stair dance” as a supportive function, he is actually preventing her from falling.

Not all older adults have a stair dancing partner, so it’s important to find another effective method of fall prevention. In a home with more than one floor, an electronic stair-lift may be appropriate if arrangements cannot be made for the individual to live fully on one floor. Recognizing trip hazards is also very important. My mother has three cats, so it’s necessary to ensure a cat is not underfoot when my grandmother moves about.

We are likely all familiar with an aging family member that is at risk of a fall. No matter how adamant they are about living on their own or continuing their daily routines without worry, any of us that work in healthcare recognize the serious risks. We want to protect our parents, our grandparents, or even our great-grandparents, but we must also respect their desires if they choose to age in their homes, even if they are doing so alone. Engage them in the conversation and review the checklists on, watch videos together and let them know you care about their safety.

CPS PSO Watch/Alert: Fall Risk

The Center for Patient Safety issues this alert regarding falls based on our data analysis.

Falls are a difficult and long-standing challenge for providers. While the majority of events report no harm, falls continue to result in severe life-changing injury or even death.  The CPS recommends you re-evaluate your fall risk program, considering the following best practices:

  • Ensure the fall risk assessment tool correlates to the daily workflow and all nurses are trained in appropriate utilization of the tool
  • Include all staff (dietary, housekeeping, maintenance personnel also) and physicians in your falls prevention program
  • Utilize a standardized communication tool to communicate the patient’s fall risk potential to the entire team
  • Make certain the preventative measure match the patient’s risk factors
  • Individualize/tailor preventative measures to meet the patient’s needs (i.e. bed alarms are not effective for all patients)
  • Include consistent patient rounding as part of your preventative measures
  • Implement a quick post-fall huddle process to quickly identify contributing factors that require a system/program change
  • Routinely/daily review medications and their effect on each patient’s fall risk potential

This alert is provided to increase awareness regarding the complex considerations required for a successful falls prevention program.



CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

What the AHRQ guidance means for providers and their patients. 11

Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

New CPS report seeks to raise awareness of safety concerns in the EMS community. 16


  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

Patient Falls in Missouri – Addressing Toolkits

Falls in Missouri Report CoverDespite a multitude of toolkits and resources, patient falls remain a prevalent safety issue. Over the past three years, falls have consistently been in The Joint Commission’s top ten reported sentinel events. In 2013 falls were the fifth most commonly reported sentinel event, rising to the second most reported event in 2014. Currently falls are the fourth most reported sentinel event through 3rd quarter of 2015.1 This is concerning in two regards: 1. Increased avoidable injury to patients, 2. Financial risk for the facility due to increased length of stay and cost of treating the fall injury.

The Missouri Hospital Association and the Center for Patient Safety (CPS) began a collaborative effort the summer of 2015 to review claims data and patient safety event data to see if Missouri was following the national landscape trend of an increasing number of falls. The time frame reviewed was October 1, 2013 through March 31, 2015. By correlating the data collected by each organization, it was hoped that a trend could be identified; and that by analyzing causal/contributing factors, there could be lessons learned in regards to falls in the state of Missouri and how to prevent them from occurring in a healthcare facility.

SEA TableAs this collaborative effort was going forth, The Joint Commission issued Sentinel Alert Event #55 on September 28, 2015.2 This alert highlighted the fact that fall prevention is a complicated process involving many moving parts.

The Missouri Hospital Association utilized HIDI Analytics claims data pertaining to falls and trauma-related harm in the state of Missouri for the time frame noted above, while CPS analyzed falls submitted to the PSO. As the Sentinel Event noted an increase in the number of falls reported as sentinel events, Missouri also noted an increasing trend in falls. Download the full report in collaboration with the Missouri Hospital Association.

TJC Sentinel Event Watch/Alert: Preventing falls and fall-related injuries in healthcare facilities

Prevention of falls according to The Joint Commission can be a difficult and complex process. While falls resulting in death/serious injury are considered to be never events, since 2009 there have been 465 such cases reported.  The most common contributing factors include:  inadequate assessment; communication failures; lack of adherence to protocols and safety practices; inadequate staff orientation, supervision, staffing levels or skill mix; deficiencies in the physical environment and lack of leadership.  Strategies outlined for prevention of falls include the following: raise awareness; establish a multi-disciplinary fall prevention team; utilize standardized/validated tools for fall risk assessment; develop patient-specific care plans; standardize practices such as hand-off communication processes, conduct post-fall huddles and continually re-assess the patient. Also of interest is that an article was recently published noting that infections can be an underlying cause of falls.  Read the full article.

Read more on falls and fall prevention in Issue 55 of The Joint Commission Sentinel Event Alert:

For more resources on fall prevention please check out this PSNet page:

Falls Awareness Week 2015

Did you know analyzing home care patient safety events reported to the Center for Patient Safety they align with hospitals which show falls are the number one reported event? The majority of falls are associated with our elderly and disabled?  One fall can triple the risk for nursing home placement?   September 23rd is the first day of Fall which kicks off Falls Awareness Week and is also Falls Prevention Awareness Day.  Please check out these resources below for fall risk assessment and fall prevention.

Remember that we can all help with preventing falls!

New Targeted Solutions Tool for Preventing Falls

The Joint Commission Center for Transforming Healthcare recently released a Targeted Solutions Tool for preventing falls.  The statistics included in their article are rather startling in that each fall on average adds 6.3 days to a hospitalization and costs roughly $14, 056.  At the Center for Patient Safety we are also seeing that over 1/5 of events associated with severe harm/death are associated with falls.

We encourage you to read the article and checkout the Joint Commission Targeted Solutions Tool.


Falls Prevention Awareness Day is Sept 23, 2014

From the Center for Healthy Aging, National Council on Aging (NCOA):

Strong Today, Falls Free ® Tomorrow

Date: September 23, 2014

The 7th annual Falls Prevention Awareness Day will be observed on September 23, 2014-the first day of fall. This year’s theme, Strong Today, Falls Free ® Tomorrow, seeks to raise awareness about how to prevent fall-related injuries among older adults.

The Falls Free ® Initiative is a national effort led by NCOA to address the growing public health issue of falls and fall-related injuries and deaths in older adults.

Fall Prevention Day

Although fall prevention is high on the minds of all caregivers, Fall Prevention Day is a day for focus.   Learn how the inpatient Rehabilitation Unit at Saint Francis Hospital in Cape Girardeau, Missouri dramatically reduced their fall rate:

“Our CUSP team has had tremendous success. Using a comprehensive approach, we have had buy-in from all levels of the organization. This shows the dedication that the Saint Francis Medical Center patient care staff has for the patients and their safety.”       – David C. Prather, CPA, Controller, Saint Francis Medical Center

Read the full story here

Fall Prevention Day is September 23, 2013

Join us as we recognize Fall Prevention Awareness Day coming up on September 23rd. Check back often for further information on Fall Prevention Day activities.

The Missouri Department of Health and Senior Services has created a great Falls Day Flash Mob Video in the Jefferson City Capital Mall – take a peek!


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.