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.

Patient Safety Awareness Week Approaches, March 12-18th

The Center for Patient Safety (CPS) encourages all healthcare organizations to use Patient Safety Awareness Week, March 12-18th, as a way to remind staff and community of your commitment to safety. It should be a time of celebration of successes, but also a time of reflection.

Free Toolkit for Patient Safety Awareness Week 2017

CPS reminds you to plan in advance for Patient Safety Awareness Week. Plans don’t have to be time consuming or extravagant, but a little planning can go a long way. We recommend hosting an event or several events to recognize patient safety efforts at your organization.

For example:

  • Recognize staff and committees that work every day to provide safe care
  • Launch a patient safety culture assessment during the week (mention this blog and receive 10% off your survey services through CPS!)
  • Have leadership, patient safety/risk/quality department and/or safety committees host events in the cafeteria with snacks or dessert or something special to celebrate safety at their organization
  • Ask departments to develop poster presentations of their successful safety efforts. Display in hallways.
  • Hang a safety awareness week poster in the foyer of the organization with signatures from all staff
  • Hold safety-focused training during Patient Safety Awareness Week
  • Publish safety-focused articles for the organization’s internal newsletter, professional newsletters, local newspapers, local consumer groups
  • Contact a local radio station to host a spokesperson to share patient safety tips and highlights
  • Launch a new safety awareness effort – a “good catch” program, implement a new “CUSP Team”, announce an upcoming “Safety Culture Survey”, etc.

Several available toolkits can support improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also suggest you consider consumer involvement to ensure a successful week. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement events and programs during Patient Safety Awareness Week:

Visit for more information and resources about #PSAW2017.

Changing Patient Safety Culture

Transparency is one of the biggest challenges in changing patient safety culture.  Frank Federico, VP at IHI, shares viewpoints in his recent blog.  Remember the CANDOR toolkit (noted in his blog) is available for free from AHRQ and can be helpful in implementing culture changes around communication with patients and family members. Read IHI blog.

AHRQ Communication and Optimal Resolution Toolkit

AHRQ has released a very useful toolkit to help health care providers communicate with patients/family members after an unexpected event that caused harm. The “Communication and Optimal Resolution” (CANDOR) toolkit includes step-by-step guidance, forms, videos and other resources to assist providers through the entire process, beginning with identification of an error to resolution with those involved.

Download the free toolkit here.

AHRQ Releases SOPS Action Planning Resource

ActionPlanningThe Agency for Healthcare Research and Quality has issued an Action Planning Tool to complement their suite of safety culture survey assessments.

The tool is meant to be used after the survey has been administered and the results have been collected. The tool helps users define goals, process measures, and initiatives to be implemented, including a framework for determining who will lead the initiatives, how resources will be distributed, and strategy planning for potential barriers.

Find out more and download the report at

Interested in surveying your organization? CPS can save you time and resources by administering the survey for your organization.  Find out more about CPS survey services.

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.

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.

Free hand hygiene tools

Need new resources for your hand hygiene program?   Winston-Salem-based Novant Health offers free downloadable posters, billboards, banners, computer wallpapers, tray liners, yard signs, screensavers, staff hand hygiene practice evaluation materials and hand hygiene protocol tips (both require email sign-up).   To download some or all of the resources, click here.   Thanks to Novant for sharing!

Safety Awareness Week is for Long-Term Care, Too!

Even though the National Patient Safety Foundation doesn’t use LTC-inclusive language in its name or the name of its Patient Safety Awareness Week, they still have much to offer our long-term care communities, including a special week to recognize our dedication to resident safety.   CPS has developed a toolkit to help ALL providers celebrate this special week from March 2-8, and to engage residents, staff and families.

In St. Louis County,Bethesda Southgate is getting its community focused on safety, using several of the CPS toolkit resources:

  • A banner to announce Patient Safety Awareness Week in the lobby
  • Posters in public areas
  • Short daily announcements with quick, targeted tips on the issue of the day, such as “Help us prevent falls and remember to use your walker or helpers”
  • Table placards with the button/sticker from the toolkit, together with tips on the safety concern for the day

Anyone interested in using the materials can access the toolkit here.   And don’t forget to share your safety success stories with a poster (submit a short application) at the CPS 8th Annual Patient Safety Conference in St. Louis on March 21.

March 2-8, 2014 is Patient Safety Awareness Week

The Center for Patient Safety is joining Patient Safety Awareness Week this March to acknowledge:

“Safe Care is Our Focus, 24 hours a day, 7 days a week, 365 days a year”

In recognizing the year-round efforts to improve safe care, the Center is raising awareness by providing tools and resources for healthcare providers and consumers for Patient Safety Awareness Week!   This is how…..

  • Patient Safety Awareness Week Toolkit – a downloadable, customizable  resource for healthcare organizations to raise awareness about patient safety efforts – banners, posters, tent cards, buttons – and tips to help you get started!
  • Consumer Tips for Safe Care – highlighting consumer guidance and resources
  • Eighth Annual Patient Safety Conference, Safe Care: Our Focus 24/7/365, on March 21 in St. Louis. In-person and live streaming options available!   For more information or to register, visit


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

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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.