Frequency Chart: Total Costs for 22 Falls

2
7
6
3
2
0
0
2
4
6
8
Total Cost Per Fall
Average: $33,785
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 fip book
Sample tools such as assessments
Sample fall prevention protocol
Articles on falls prevention
Video on fall prevention
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:
- ackground information on falls
- The reason and method of the development of the Falls Toolkit
- The information and resources inside the Falls Toolkit! and
- "ow to use the Falls Toolkit
Background Information on Falls
#alls among the elderly are an important and timely issue. According to the $enters for %isease $ontrol!
&ational $enter for 'n(ury Prevention and $ontrol! #alls are the leading cause of death due to in(ury for
people aged )* years and older +&$'P$! ,--,.. /ach year! 0*1 of nursing home residents are e2pected
to fall +3u4enstein! 5667.. 8ith 50 to 9,1 mortality! hip fractures are one of the most serious
conse:uences of falls among the elderly +;annis! et al. ,--9.. Studies have estimated that there will 4e
*--!--- hip fractures per year ,-7- +$ooper 566,! rainsky 5660..
The financial impact of falls can 4e
su4stantial. At a Patient Safety ,-,
training provided 4y &$PS! Patient
Safety Managers were asked to
provide %SS cost information for
one of three types of adverse events!
one of which was falls. Twenty-two
facilities provided information
regarding the cost of falls with
in(ury. The average cost of a fall
with in(ury was <99!0=*! with a
range 4etween <5=- and <,7-!---.
Reason & Method of Development of the Falls Toolkit
'n ,--9! falls represented nearly 701 of all Safety 3eports and aggregated events in the &$PS SP>T
data4ase. As of March ,--7! falls represented 551 of 3oot $ause Analyses occurring in calendar year
,--9.
To confirm the need for the falls toolkit!
the #alls Aggregate 3eview survey of
Patient Safety Managers included a
:uestion a4out the toolkit. The
:uestion asked what information or
resources Patient Safety Managers
would like to see included. This
information was drawn upon in
creating the toolkit.
'n an effort to ensure that the #alls Toolkit would 4e useful! &$PS 4eta-tested the toolkit with =
facilities and one su4(ect matter e2pert. The facilities were asked to review the contents of the
%epartment of Veterans Affairs 0?,-?-7 Page 5 of 7
&ational $enter for Patient Safety


/ducational 3esource @uide
The Falls Toolkit: An Introduction
toolkit for a month and complete a survey. The facilities found the toolkit useful! practical and
easy to understand. Additionally! 4ased on the feed4ack from the facilities and the su4(ect matter
e2pert! &$PS added articles to the annotated resource list! changed the format of the toolkit!
modified the videos! and added sections.
Inside the Falls Toolkit
The #alls Toolkit is a 4o2 set containing a note4ook and a media 4o2.
The Falls Toolkit Notebook
The note4ook is a three ring 4inder containing 55 ta44ed sections. The inside cover of the 4inder
includes a $%-3>M of the falls toolkit we4site! a Morse #all Scale Pocket $ard! two tri-fold
4rochures and three = A 4y 55B posters and fliers. At the front of the 4inder is a letter from %r.
agian. The 55 ta44ed sections are as follows:
$ontents - contains the locations of all the resources availa4le in the toolkit
'nstructions - how to use the toolkit
ackground - general information on falls and fall prevention
#alls Team - how to develop an interdisciplinary falls team
#alls Policy - what should 4e in a comprehensive fall prevention policy and an e2ample
policy
'nterventions - interventions to reduce the num4er of falls and the in(uries related to falls
Measuring Success - tools to measure the improvement in falls and in(uries due to the
interventions
3esources - additional articles and resources categoriCed 4y topic
Video 5 - resources for the video: Performing a alance Assessment +Audience:
3eha4ilitation Therapists.
Video , - resources for the video: "ip Protectors in an 'npatient Setting +Audience:
$aregivers.
Video 9 - resources for the video: Protecting your hips with hip protectors +Audience:
Patients.
The $%-3>M of the we4site contains all the information in the toolkit with the e2ception of the
videos. Additionally! the $%-3>M and we4site contain resources that are not printed in the
toolkit! such as the /ducational 3esource @uide and the Technology Assessment @uide.
#alls Toolkit 8e4site
%epartment of Veterans Affairs 0?,-?-7 Page , of 7
&ational $enter for Patient Safety
The Falls Toolkit: An Introduction
The Falls Toolkit Media Box
The media 4o2 is a Velcro fastened 4o2 that contains three 55B 4y 50B posters! three video $%s
each containing one of the videos mentioned a4ove! 5 V"S tape containing all three videos and a
small 4o2 containing two styles of sample 4uttons for identifying falls prevention advocates or
resources on units or shifts.
The Falls Toolkit Website
The #alls Toolkit we4site contains all the printed information and tools availa4le on the we4site
and some additional materials such as the Technology Assessment @uide and the /ducational
3esource @uide. 'n addition! the we4site will 4e updated annually as new research 4ecomes
availa4le. The we4site is availa4le at:
vaww.ncps.med.va.gov?falls toolkit and www.patientsafety.gov.
The we4site is organiCed into five sections:
@etting Started - contains orientation materials for the #alls
Toolkit
The &ote4ook - contains P%# and 8ord versions of the
information in the note4ook
Media Tools - contains P%# versions of the posters! fliers!
4rochures! 4utton designs.
3esources - contains P%# and 8ord versions of the
additional resources +Technology Assessment @uide and
/ducational 3esource @uide see page 2.! PowerPoint
presentations! /2cel files! 4utton designs and links to
relevant we4sites.
$ontact 'nformation - provides information on how to
contact &$PS for more information! :uestions or comments.
%epartment of Veterans Affairs 0?,-?-7 Page 9 of 7
&ational $enter for Patient Safety

The Falls Toolkit: An Introduction
Distribution lan
/ach Patient Safety Manager will receive two copies of the #alls Toolkit. Additionally! 9 copies
will 4e sent to each V'S& Patient Safety >fficer. Materials will also 4e on the &$PS internet
and intranet we4sites.
!sing the Falls Toolkit
The purpose of the #alls 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
4e coordinated across disciplines and care areas. The Aggregated 3eview Team for falls can use
the toolkit to analyCe the data collected as part of the root cause analysis and develop actions and
outcome measures to reduce falls and fall-related in(uries.
The #alls 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. #ront-line care staff
can use the toolkit to implement evidence-4ased interventions 4ased on fall-risk or a patientDs
areas of risk.
"ontacting the #A $ational "enter for atient %afet&
'f you have :uestions or comments a4out the #alls Toolkit! you can contact Amelia Eandesman
or /rik Stalhandske. They can 4e reached 4y phone at +097. 69--*=6- or 4y email at
Amelia.EandesmanFmed.va.gov or /rik.StalhandskeFmed.va.gov.
%epartment of Veterans Affairs 0?,-?-7 Page 7 of 7
&ational $enter for Patient Safety
utton %esigns