The Falls Toolkit: An Introduction

This is an informational monograph to help introduce the NCPS Falls Toolkit to Patient Safety Managers
and others within and outside of the Veterans Administration.
This informational package covers the following information:
- Background information on falls
- The reason and method of the development of the Falls Toolkit
- The information and resources inside the Falls Toolkit, and
- How to use the Falls Toolkit

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).
Frequency Chart: Total Costs for 22 Falls
The financial impact of falls can be
substantial. At a Patient Safety 202 Average: $33,785
training provided by NCPS, Patient 8 7
Safety Managers were asked to 6
Frequency (# of falls)

provide DSS cost information for 6

one of three types of adverse events, 4 3
one of which was falls. Twenty-two 2 2
facilities provided information 2
regarding the cost of falls with 0
injury. The average cost of a fall 0
5
00
0 00 00 00 00 00 ,00
0 00
-19
with injury was $33,785, with a $1
80
$1
95
-5
,00
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o2
0 ,0

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00
t o3
5,0

$3
5,0
00
-50
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$5
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00
-80
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00
t o$
15
0,0

00
to
$2
20

20
,00
0-2
50
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$5 $2 0,0 0,0 $2
range between $180 and $240,000. $8 $1
5

Total Cost Per Fall

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.

Video on fall prevention

To confirm the need for the falls toolkit,
Articles on falls prevention
the Falls Aggregate Review survey of
Patient Safety Managers included a Sample fall prevention protocol

question about the toolkit. The question Sample tools such as assessments

asked what information or resources Falls flip book

Patient Safety Managers would like to see List of vendors

included. This information was drawn Falling stars that identify pt at high risk
upon in creating the toolkit.
White board or dry erase board for pt assess

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

In an effort to ensure that the Falls Toolkit would be useful, NCPS beta-tested the toolkit with 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

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 The Falls Toolkit: An Introduction

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, modified the videos, and added sections.

Inside the Falls Toolkit

The Falls Toolkit is a box set containing a notebook and a media box.

The Falls Toolkit Notebook

The notebook is a three ring binder containing 11 tabbed sections. The inside cover of the binder
includes a CD-ROM of the falls toolkit website, a Morse Fall Scale Pocket Card, two tri-fold
brochures and three 8 ½” by 11” posters and fliers. At the front of the binder is a letter from Dr.
Bagian. The 11 tabbed sections are as follows:
• Contents - contains the locations of all the resources available in the toolkit
• Instructions - how to use the toolkit
• Background - general information on falls and fall prevention
• 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
• Video 1 - resources for the video: Performing a Balance Assessment (Audience:
Rehabilitation Therapists)
• Video 2 - resources for the video: Hip Protectors in an Inpatient Setting (Audience:
Caregivers)
• Video 3 - resources for the video: Protecting your hips with hip protectors (Audience:
Patients)

The CD-ROM of the website contains all the information in the toolkit with the exception of the
videos. Additionally, the CD-ROM and website contain resources that are not printed in the
toolkit, such as the Educational Resource Guide and the Technology Assessment Guide.

Falls Toolkit Website

Educational Resource Guide

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 The Falls Toolkit: An Introduction

The Falls Toolkit Media Box

The media box is a Velcro fastened box that contains three 11” by 17” posters, three video CDs
each containing one of the videos mentioned above, 1 VHS tape containing all three videos and a
small box containing two styles of sample buttons for identifying falls prevention advocates or
resources on units or shifts.

The Falls Toolkit Website

The Falls Toolkit website contains all the printed information and tools available on the website
and some additional materials such as the Technology Assessment Guide and the Educational
Resource Guide. In addition, the website will be updated annually as new research becomes
available. The website is available at:
vaww.ncps.med.va.gov/falls toolkit and www.patientsafety.gov.

The website is organized into five sections:

Getting Started - contains orientation materials for the Falls

Toolkit

The Notebook - contains PDF and Word versions of the

information in the notebook

Media Tools - contains PDF versions of the posters, fliers,

brochures, button designs.

Resources - contains PDF and Word versions of the

additional resources (Technology Assessment Guide and
Educational Resource Guide see page 2), PowerPoint
presentations, Excel files, button designs and links to
relevant websites.

Contact Information - provides information on how to

contact NCPS for more information, questions or comments.

Distribution Plan
Each Patient Safety Manager will receive two copies of the Falls Toolkit. Additionally, 3 copies
will be sent to each VISN Patient Safety Officer. Materials will also be on the NCPS internet
and intranet websites.

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

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 The Falls Toolkit: An Introduction

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. 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.

Contacting the VA National Center for Patient Safety

If you have questions or comments about the Falls Toolkit, you can contact Amelia Landesman
or Erik Stalhandske. They can be reached by phone at (734) 930-5890 or by email at
[email protected] or [email protected].

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