Reducing Hospital Falls With Reflective Accountability Instead of Socks and Signs

Margaret R. Nolan, DNP, GNP


June 21, 2016

Beyond Socks, Signs, and Alarms: A Reflective Accountability Model for Fall Prevention

Hoke LM, Guarracino D
Am J Nurs. 2016;116:42-47

The Old Ways to Prevent Falls Aren't Good Enough

Even with fall reduction programs in place, falls continue to be a significant problem for hospitalized patients. Falls are a perennial top adverse event in inpatient settings, occurring more frequently than catheter-associated urinary tract infections. Falls are associated with increased morbidity and mortality, longer length of stay, higher cost of hospitalization, and more litigation from families.

This article describes the efforts of nurses to reduce the rate of falls in a cardiac intermediate care unit. Standard efforts included elements of The Joint Commission and Agency for Healthcare Research and Quality (AHRQ) recommendations, including routinely assessing patients using the Morse fall scale, using nonskid socks, posting signs to alert patients and families to call for aid before getting out of bed, using bed and chair alarms, and applying other fall prevention tips. Despite these measures, the unit experienced an overall increase in falls. The nurses felt great frustration that their efforts did not reduce overall fall incidents.

New Practices and a Culture of Reflective Accountability

The hospital assembled a group of nurses to form a fall prevention committee. Through reviewing research and best practices, they developed an educational plan to implement a new program for fall reduction. They also reviewed the falls that had occurred recently in the unit. The group found that most falls occurred during toileting and brainstormed ways to change nursing culture and motivate staff to participate in these changes. The changes included the following:

  • Weekly informal meetings;

  • Self-reflective emails to all staff members from the nurse whose patient fell, including the nurse's description of how and why the fall occurred, a list of factors that might have contributed to the fall, the patient's perspective on the fall, and the nurse's reflection on what might have prevented the fall;

  • Post-fall huddles to explore the causes of falls among all staff members;

  • All nursing staff and certified nursing assistants wear locator badges that track their speed in answering call lights and a general policy to answer call lights within 60 seconds; and

  • Creative ways to accompany a patient during toileting, while giving patients privacy, such as staying behind a curtain or leaving a door slightly open.

Applying the concept of reflective accountability to falls involves holding nurses accountable for falls that occur among their patients. An email that came from a peer rather than from a manager allowed for a personal connection among the staff nurses.

Implementing this program achieved a 55% reduction in overall falls (from 3.1 to 1.39 per 1000 patient-days) and a 72% reduction in injuries associated with falls (from 1.24 to 0.35 per 1000 patient-days) in the course of 1 year. Prompt call bell response contributed to the reductions in fall and injury rates. The locator badges helped to track staff members who made patient safety goals a priority and reward them during their annual performance reviews. Nurses were also able to improve their communication about a patient's fall risk with the patient and family.


Falls in the elderly are problematic in all environments, occurring in 30%-40% of all elderly persons living at home and 50% of those residing in long-term care facilities.[1] Of all hospitalized patients, 3%-20% will fall during their stay.[2] Falls are the seventh leading cause of death in persons aged 65 years or older in the United States.[1]

This article shows that enhanced programs to prevent falls are needed because the problem of falls is still widespread. The Joint Commission has said that falls are a prevalent patient safety problem and that preventing falls must be a priority in all healthcare facilities.[3] The National Quality Forum considers falls "never events," or events that should never occur in inpatient facilities.[2] The Centers for Medicare & Medicaid Services (CMS) includes falls in their list of hospital-acquired conditions and will no longer cover costs associated with preventable falls.[2] Since 2008, CMS is not reimbursing hospitals and other healthcare facilities for secondary diagnoses not present on admission.[3]

Many organizations have developed fall prevention guidelines. The Joint Commission[4] has developed a robust falls prevention program comprising six components:

  • Raise awareness;

  • Interdisciplinary participation;

  • Use of a standardized tool for fall-risk assessment;

  • Use of individualized, patient-specific fall prevention plans;

  • Standardizing evidence-based practices (communication, patient education); and

  • Conduct post-fall huddles to review fall incidents and create future planning.

The AHRQ includes post-fall review, patient education, staff education, nonslip footwear, scheduled and supervised toileting, and medication review as methods of fall prevention for inpatients.[2] Many hospitals participate in collecting data for analysis on their overall fall rates through the National Database for Nursing Quality Indicators.[2] These data allow facilities to compare their fall rates with national benchmarking standards and help facilities set realistic expectations about fall rates.[2]

Fall risk assessment varies from facility to facility, and individualized assessment can be influenced by the experience level of the nurse doing the assessment. Fall risk assessment tools created by the facility can be unreliable statistically.[5]

Using the minimum standards from The Joint Commission and AHRQ is a good place to begin a fall reduction program, but it is not enough. There is great need for nurses to take an active part in using valid risk screening tools and creating patient-specific fall prevention plans that include the interdisciplinary team, the patient, and the family. Reflective accountability is a way to enlist nursing staff at the bedside who can make the biggest impact on fall reduction.



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