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

![](media/image1.wmf)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).

The financial impact of falls can be substantial. At a Patient Safety
202 training provided by NCPS, Patient Safety Managers were asked to
provide DSS 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 injury. The average cost of a fall with
injury was \$33,785, with a range between \$180 and \$240,000.

# 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.

![](media/image2.wmf)

# 

# To confirm the need for the falls toolkit, the Falls Aggregate Review survey of Patient Safety Managers included a question about the toolkit. The question asked what information or resources Patient Safety Managers would like to see included. This information was drawn upon in creating the toolkit. 

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 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.

![](media/image3.wmf)

Falls Toolkit Website

![](media/image4.png){width="3.625in" height="2.3006944444444444in"}

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### *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](http://vaww.ncps.med.va.gov/fallstoolkit) and
[www.patientsafety.gov](http://www.patientsafety.gov/).

The website is organized into five sections:

> ![](media/image5.png){width="2.2222222222222223in"
> height="1.1888888888888889in"}[Getting Started]{.underline} - contains
> orientation materials for the Falls Toolkit
>
> [The Notebook]{.underline} - contains PDF and Word versions of the
> information in the notebook
>
> ![](media/image6.wmf)
>
> [Media Tools]{.underline} - contains PDF versions of the posters,
> fliers, brochures, button designs.
>
> [Resources]{.underline} - 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]{.underline} - 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 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 <Amelia.Landesman@med.va.gov> or
<Erik.Stalhandske@med.va.gov>.