Chapter 10. Fall and Injury Prevention 

Leanne Currie 

Background 

Fall and injury prevention continues to be a considerable challenge across the care continuum. 

In the United States, unintentional falls are the most common cause of nonfatal injuries for 

people older than 65 years. Up to 32 percent of community-dwelling individuals over the age of 

65 fall each year, and females fall more frequently than males in this age group.1, 2 Fall-related 

injuries are the most common cause of accidental death in those over the age of 65, resulting in 

approximately 41 fall-related deaths per 100,000 people per year. In general, injury and mortality 

rates rise dramatically for both males and females across the races after the age of 85, but males 

older than 85 are more likely to die from a fall than females.2-6 Unfortunately, fall-related death 

rates in the United States increased between 1999 and 2004, from 29 to 41 per 100,000 

population.2, 7 Sadly, these rates are moving away from the Healthy People 2010 fall-prevention 

goal, which specifically seeks to reduce the number of deaths resulting from falls among those 

age 65 or older from the 2003 baseline of 38 per 100,000 population to no more than 34 per 

100,000.8 Thus, falls are a growing public health problem that needs to be addressed. 

The sequelae from falls are costly. Fall-related injuries account for up to 15 percent of 

rehospitalizations in the first month after discharge from hospital.9 Based on data from 2000, 

total annual estimated costs were between $16 billion and $19 billion for nonfatal, fall-related 

injuries and approximately $170 million dollars for fall-related deaths across care settings in the 

community.10, 11 Several factors have been implicated as causes of falls and injuries; to date, 

however, no definitive predictor profile has been identified. Although the underlying status of 

the individual who sustains a fall may contribute to the fall and subsequent injury, the trauma 

resulting from the fall itself is most often the cause of morbidity and mortality. 

Over the past 20 years gerontology researchers, spearheaded by Mary Tinnetti from Yale 

University, have carried out a significant amount of research to address the problem of falls and 

injuries in the community. However, ubiquitous use of successful interventions is not yet in place 

in the community. As health care moves toward patient-centered care, and as a growing body of 

research provides guidance for widespread fall-prevention programs, fall- and fall-related-injury 

prevention now has the potential to be addressed across the care continuum. 

Inpatient fall prevention has been an individual area of concern for nursing for almost 50 

years.12, 13 Traditional hospital-based incident reports deem all inpatient falls to be avoidable, and 

therefore falls are classified as adverse events. Indeed, falls are the most frequently reported 

adverse events in the adult inpatient setting. But underreporting of fall events is possible, so 

injury reporting is likely a more consistent quality measure over time and organizations should 

consider judging the effects of interventions based on injury rates, not only fall rates. Inpatient 

fall rates range from 1.7 to 25 falls per 1,000 patient days, depending on the care area, with 

geropsychiatric patients having the highest risk.14-18 Extrapolated hospital fall statistics indicate 

that the overall risk of a patient falling in the acute care setting is approximately 1.9 to 3 percent 

of all hospitalizations.16-18 In the United States, there are approximately 37 million 

hospitalizations each year;19 therefore, the resultant number of falls in hospitals could reach more 

than 1 million per year. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Injuries are reported to occur in approximately 6 to 44 percent of acute inpatient falls.5, 20-23

Serious injuries from falls, such as head injuries or fractures, occur less frequently, 2 to 8 percent, 

but result in approximately 90,000 serious injuries across the United States each year.20 Fallrelated deaths in the inpatient environment are a relatively rare occurrence. Although less than 1 

percent of inpatient falls result in death, this translates to approximately 11,000 fatal falls in the 

hospital environment per year nationwide. Since falls are considered preventable, fatal fallrelated injuries should never occur while a patient is under hospital care. 

In the long-term care setting, 29 percent to 55 percent of residents are reported to fall during 

their stay.24, 25 In this group, injury rates are reported to be up to 20 percent, twice that of 

community-dwelling elderly. The increase in injury rates is likely because long-term care 

residents are more vulnerable than those who can function in the community.26 Rubenstein27

reported 1,800 long-term care fatal falls in the United States during1988. The current number of 

long-term care fatal falls has not been estimated; however, there are 16,000 nursing homes in the 

United States caring for 1.5 million residents in 2004.28 This population will likely grow in the 

coming years, thus fall and injury prevention remains of utmost concern. 

Fall and Fall-Related Injury Reporting

Falls and related injuries have consistently been associated with the quality of nursing care in 

the acute care setting. They are included as a nursing-quality indicator monitored by the 

American Nurses Association, National Database of Nursing Quality Indicators (ANA–NDNQI) 

and by the National Quality Forum.29, 30 Participation in the ANA–NDNQI provides hospitals 

with the ability to view their fall and injury rates in relation to other hospitals of similar type and 

size. However, participation in ANA–NDNQI is voluntary; despite a rapidly growing 

participation rate, it is not yet ubiquitous (1,089 hospitals as of June 2007, approximately 15 

percent of U.S. hospitals). The National Quality Forum also advocates for voluntary reporting of 

quality indicators for acute care (falls prevalence and fall-related injuries) and ambulatory care 

(fall-risk screening for geriatrics).31, 32

The Maryland Quality Indicator Project is a second voluntary national repository that 

provides fall and fall-related injury benchmarks for the behavioral health, long-term care, and 

home care settings.33 Unfortunately, this project has a participation level of approximately 1,000 

hospitals (approximately 14 percent), making national benchmarking difficult. In the home care 

setting, the Centers for Medicare & Medicaid Service’s Outcome and Assessment Information 

Set (CMS–OASIS) provides the reporting basis for the patients’ physical functioning.34 Growing 

efforts to expand patient safety initiatives to the home care setting seek to include falls as a 

quality indicator for patients who are cared for at home, but who are not completely bed bound.35, 

36 Collection of these data has the potential for organizations to track fall rates of vulnerable 

patients and to identify patients at risk for falls and injuries. However, further research is 

required to validate such screening and to examine which interventions are effective based on 

risk status. 

In the nursing home setting, the long-term care minimum dataset (LTCMDS) is used for 

reporting all aspects of care. The LTCMDS captures fall and injury histories via assessments that 

are performed on admission and at regular intervals during a resident’s stay.37 In addition, 

residents are evaluated for balance and for the ability to perform activities of daily living (ADLs), 

with the goal to apply fall-prevention measures should the patient be deficient in these areas. 

Recent research by Hill-Westmoreland and Gruber-Baldini38 indicated only a 75 percent 

2 
Fall and Injury Prevention

concordance between chart abstraction and minimum dataset reporting for a group of long-term 

care facilities. A more recent development in the long-term care setting, the Nursing Home 

Quality Initiative, promotes the collection of a list of enhanced quality indicators, including those 

that track declines in functional and cognitive status.34, 37 The Agency for Healthcare Research 

and Quality (AHRQ) has elected to monitor only postoperative hip fracture as their fall-related 

preventive quality indicator, which is consistent with thinking that monitoring fall-related 

injuries is a more dependable measure of quality.39, 40 However, tracking of all fractures would 

be of benefit. The Health Plan Employer Data and Information Set has recently added Fall Risk 

Assessment to its dataset, which will provide a method to benchmark the evaluation of fall risk 

between health insurance providers.41 However, application of fall- and injury-prevention 

programs is not included as an indicator, which will make it difficult to benchmark these 

important measures. Increased and more accurate monitoring of these elements has the potential 

to reduce falls among nursing home residents; however, the effect of these efforts has yet to be 

established. 

Definitions of Falls and Fall-Related Injuries 

Falls and related injuries have had varying definitions.42, 43 Falls may be precipitated by 

intrinsic or extrinsic factors. Intrinsic factors are those that have a physiologic origin, and 

extrinsic factors are those precipitating from environmental or other hazards. Distinguishing 

between intrinsic or extrinsic risk factors can facilitate identification of preventive strategies. 

According to Tinetti, Speechley, and Ginter,44 a fall in the nonhospitalized geriatric population is 

defined as “an event which results in a person coming to rest unintentionally on the ground or 

lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard.” 

Agostini, Baker, and Bogardus45 adapted this definition for the inpatient, acute, and long-term 

care areas to define a fall as “unintentionally coming to rest on the ground, floor, or other lower 

level, but not as a result of syncope or overwhelming external force.” 

Other definitions are broader and include falls related to intrinsic events such as syncope or 

stroke. For example, Nevitt’s46 definition of a fall is “falling all the way down to the floor or 

ground, or falling and hitting an object like a chair or stair.” The ANA–NDNQI provides an allinclusive definition47 (p. 26): 

An unplanned descent to the floor (or extension of the floor, e.g., trash can or 

other equipment) with or without injury. All types of falls are included, whether 

they result from physiological reasons or environmental reasons. 

The International Classification of Diseases 9 Clinical Modifications (ICD-9-CM) uses 

several codes to categorize falls, all of which have broad descriptions: Accidentally bumping 

against moving object caused by crowd with subsequent fall (E917.6); Fall on or from ladders or 

scaffolding (E881); Fall from or out of building or other structure (E882); Other fall from one 

level to another (E884); Fall on same level from slipping, tripping, or stumbling (E885); Fall on 

same level from collision, pushing, or shoving by or with another person (E886); and Other and 

unspecified fall (E888).48 In the inpatient care setting, E888 is the code that is typically used to 

record a fall in a medical record. However, this ICD-9-CM code is not consistently used for 

reporting; therefore, institutions generally rely on incident reports as the method of counting fall 

events.48

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Fall-related injuries in the community, home care, and long-term care areas are generally 

characterized by ICD-9-CM diagnoses for the related injured body part. In contrast, incident 

reports in the acute care setting use the following ANA–NDNQI fall-related injuries categories: 

(1) None indicates that the patient did not sustain an injury secondary to the fall. 

(2) Minor indicates those injuries requiring a simple intervention. 

(3) Moderate indicates injuries requiring sutures or splints. 

(4) Major injuries are those that require surgery, casting, further examination (e.g., for a 

neurological injury). 

(5) Deaths refers to those that result from injuries sustained from the fall.29 

According to Morse,21 inpatient falls can be classified into three categories: accidental falls 

(derived from extrinsic factors, such as environmental considerations), anticipated physiologic 

falls (derived from intrinsic physiologic factors, such as confusion), and unanticipated 

physiologic falls (derived from unexpected intrinsic events, such as a new onset syncopal event 

or a major intrinsic event such as stroke). Morse asserts that using this classification, 

approximately 78 percent of the falls related to anticipated physiologic events can be identified 

early, and safety measures can be applied to prevent the fall. Research to identify precursors to 

unexpected intrinsic events, such as screening for predictors of syncopal events, might increase 

the early identification of anticipated physiologic falls, which could ultimately prevent more 

falls.49-51 

Falls and Fall-Related Injuries as Medical Errors 

The definition of a fall is consistent with that of a medical error: “the failure of a planned 

action to be completed as intended” (i.e., error of execution) or “the use of a wrong plan to 

achieve an aim” (i.e., error of planning).52, 53 For example, an error of execution might be the 

failure to perform the planned action of placing a call light within the patient’s reach, and an 

error in planning might be to provide aggressive physical therapy before a patient's balance has 

been established. An error of commission is “an error that occurs as a result of an action taken,” 

for example, a fall that occurs subsequent to a behavioral health patient's electroconvulsive 

therapy. An error of omission, “an error which occurs as a result of an action not taken,” might 

occur if the patient is not assessed for fall and injury risk, which prevents appropriate 

interventions from being applied. Latent errors related to fall and injury prevention are those in 

which an agency does not apply appropriate standards, training, or support for the practice-based 

fall- and injury-prevention processes. Recent efforts by the Joint Commission (formerly the Joint 

Commission on Accreditation of Healthcare Organizations [JCAHO]) in its National Patient 

Safety Goals advocate for institution-wide risk assessment for falls and documentation of a fallprevention program.54 These efforts have the potential to eliminate latent errors related to falls 

and injuries. Monitoring errors might occur if the patient is not monitored to identify fall risk, or 

if the patient is not monitored to identify a post-fall injury such as a subdural hematoma. 

This review summarizes the current research related to fall and injury prevention. The 

chapter is organized to present research from two perspectives: (1) community setting, and (2) 

acute and long-term settings. For each setting, the research that addresses risk factors, risk 

assessment instruments, and fall- and injury-prevention interventions are reviewed. Reports on 

the outcomes of fall- and injury-prevention research using experimental or quasi-experimental 

research design is summarized in tables at the end of the chapter. 

4 
Fall and Injury Prevention

Research Evidence 

Falls and Related Injuries in the Community 

In the following section, research about falls and related injuries in the community were 

identified and categorized as follows: risk factor identification, risk assessment instruments, and 

prevention strategies. 

Risk factors in the community. The pivotal research of Tinetti, Speechly and Ginter44

related to fall and injury prevention in community-dwelling individuals older than 65 years 

identified the following risk factors for falling: (1) postural hypotension, (2) use of any 

benzodiazepine or sedative-hypnotics, (3) use of four or more prescription medications, (4) 

environmental hazards, and (5) muscular strength or range of motion impairments. Other 

researchers have identified additional patient or treatment risk factors: (1) comorbidities, 

including diabetes, diabetic foot ulcer,55 stroke,56 syncope,57 anemia,58, 59 Alzheimer’s disease,60

Parkinson’s disease,61 vitamin D deficiency,62, 63 and vitamin D deficiency in combination with 

low creatinine clearance;64 (2) patient characteristics, including fallophobia (also known as “fear 

of falling”),65, 66 gait problems (e.g., weakness and impaired sensation),67 postural hypotension, 

inability to get out of chair, impaired ability to perform ADLs, frailty,68-70 inability to follow 

instructions,71 and inability to adapt to changing environment;72 and (3) other characteristics, 

including recent hospitalization,9 nonsupportive footwear (e.g., slippers),73 reckless wheelchair 

use,74 environmental hazards, and use of psychotropic medication.75, 76 Age and gender are also 

associated with falls and fall-related morbidity and mortality. Fall rates increase with age,77 and 

in community-dwellers between 65 and 85 years of age, females are more likely to fall, but 

males are more likely to die from fall-related injuries than females in this group.1, 2 

The roles of ethnicity and race in relation to falls and injury have also been studied. ReyesOrtiz and colleagues78 examined risk factors for Mexican-Americans and found that in the 

community, the risk factors are the same as for their White counterparts. Hanlon and colleagues79

examined predictors of falls between Caucasians and African Americans and found that African 

Americans were 23 percent less likely to fall than Whites (odds ratio = 0.77). Faulkner and 

colleagues80 explored this difference in women and found that Caucasian women were 50 

percent more likely to fall than African American women, although this was not statistically 

significant (relative risk = 1.50, 95% confidence interval [95% CI] = 0.90–2.49). The researchers 

further examined situations leading to falls and found that circumstances differed by ethnicity: 

Caucasian women were more likely to fall outdoors versus indoors (odds ratio = 1.6, 95% CI = 

1.0–2.7) and laterally versus forward (odds ratio = 2.0, 95% CI = 1.1–3.4), but less likely to fall 

on the hand or wrist (odds ratio = 0.6, 95% CI = 0.3–1.0). This research suggests that activities 

differ between older African American women and their Caucasian counterparts and should be 

considered when making fall- and injury-prevention plans. 

Risk factors for injury in the community. Risk factors for injury in the community are 

increasingly well characterized. Porthouse and her research team81 performed a comprehensive 

cohort study of almost 4,300 women older than 70 years and confirmed the following risk factors 

for various types of fall-related fractures: (1) fall in the past 12 months, (2) increasing age, (3) 

previous fracture, and (4) low body weight. This work also identified that smoking was not 

associated with fracture risk. A growing body of research is examining vitamin D deficiency as a 

risk factor for fracture; however, results are conflicting to date, but bear further research.81, 82 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Colon-Emeric and colleagues83 used data from a large community epidemiologic study to 

identify whether historical and functional information could help to predict fracture risk. The 

researchers identified nine characteristics that were predictors of fracture: (1) female sex, (2) age 

greater than 75 years, (3) White race, (4) body mass index (BMI) of less than 22.8 kg/m2

, (5) 

history of stroke, (6) cognitive impairment, (7) one or more ADL impairments, (8) one or more 

Rosow-Breslau impairments (e.g., perform heavy work, walk a mile, climb stairs), and (9) 

antiepileptic drug use. Ohm and colleagues84 recently identified that elderly community-dwelling 

individuals with traumatic head injuries were more likely to die based on the use of antiplatelet 

therapy (relative risk = 2.5 for those taking antiplatelet therapies; P = 0.016). A similar body of 

research related to chronic subdural hematomas has identified that patients on anticoagulant or 

antiplatelet therapy are at higher risk for chronic subdural hematoma and that many of these are 

first identified when a patient is evaluated after a fall.85 Many injury risk factors are consistent 

with fall risk factors, accentuating the need for effective screening of elderly communitydwelling individuals. However, factors that make people more susceptible to injury, such as 

antiplatelet therapy, establish the need for additional safety measures for individuals at risk for 

injury. Table 1 lists the intrinsic and extrinsic risk factors for falls, injuries, and fall-related 

deaths in the community. 

Table 1. Risk Factors for Falls, Injuries, and Fall-Related Deaths in the Community 

Intrinsic Risk Factors Fall Risk Injury Risk Mortality Risk 

Demographics 

• Age: Older Age (especially >70yrs) Yes Yes Yes 

• Gender Female Female Male >85 

• Race Caucasian Caucasian Caucasian 

Cognitive Function 

• Cognitive impairment Yes No data No data 

• Fallophobia (fear of falling) Yes Yes No data 

• Inability to follow instructions Yes No data No data 

• Inability to adapt to changing environment Yes No data No data 

Physical Function 

• Gait problems Yes No data No data 

• Impaired ability to perform ADLs Yes Yes No data 

• Impaired muscle strength or range of motion Yes Yes No data 

• Poor/fair self-reported health Yes Yes No data 

• Rosow-Breslau impairment No data Yes No data 

• Vision problems Yes No data No data 

Physical Status 

• BMI less than 22.8 kg/m2 No data Yes Yes 

• Frailty No data Yes Yes 

• Low body weight (<58 kg=BMI 23 if height 5’3”) Yes Yes No data 

Comorbidities 

• Alzheimer disease Yes No data No data 

• Anemia (including mild anemia) Yes No data No data 

• Diabetes Yes No data No data 

• Diabetic foot ulcer Yes No data No data 

• Fall in the past 12 months Yes Yes No data 

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Fall and Injury Prevention

Intrinsic Risk Factors Fall Risk Injury Risk Mortality Risk 

• Parkinson disease Yes No data No data 

• Postural hypotension Yes No data No data 

• Previous fracture No data Yes No data 

• Stroke Yes Yes No data 

• Subdural hematoma (chronic) Yes Yes No data 

• Syncope Yes No data No data 

• Vitamin D deficiency Yes Yes No data 

• Vitamin D deficient w/ low creatinine clearance Yes No data No data 

Medications 

• Use of 4 or more medications Yes No data No data 

• Anti-epileptics No data Yes No data 

• Antihypertensives Yes No data No data 

• Antiplatelet therapy No data No data Yes 

• Psychotropics Yes No data No data 

• Sedatives and hypnotics Yes No data No data 

Extrinsic Risk Factors Fall Risk Injury Risk Mortality Risk 

• Environmental hazards Yes No data No data 

• Footwear, non-supportive (e.g., slippers) Yes No data No data 

• Hospitalization, recent Yes No data No data 

• Wheelchair use, reckless wheelchair use Yes No data No data 

Risk assessment instruments for community dwellers. Tinetti86 developed a fall risk 

assessment index based on the following nine risk factors: mobility, morale, mental status, 

distance vision, hearing, postural blood pressure, back examination, medications, and ability to 

perform ADLs. This instrument has been the most widely used and tested, with a reported 

sensitivity of 80 percent and specificity of 74 percent.87 Other instruments used in the 

community include the following (with reported sensitivities and specificities in parentheses): (1) 

Berg Balance Test (sensitivity = 77 percent; specificity = 86 percent), (2) Elderly Fall Screening 

Test (sensitivity = 93 percent; specificity = 78 percent), (3) Dynamic Gait Index (sensitivity = 85 

percent; specificity = 38 percent), and (4) Timed Get Up and Go test (sensitivity = 87 percent; 

specificity = 87 percent).87 Aside from the Timed Get Up and Go test, which takes less than a 

minute for a health care provider to administer, these instruments generally take 15 to 20 minutes 

to complete.87 

Lord and colleagues88 recently evaluated the effect of an exercise-related fall-prevention 

program, but found that the intervention was not useful in community dwellers who were not 

screened for risk. The researchers concluded that screening to identify individuals at high risk for 

falls would be necessary for a successful fall-prevention program. Further research to identify the 

most accurate, yet easy-to-use risk assessment instrument would be necessary to move these 

efforts forward. 

A recent systematic review by Scott and colleagues89 examined fall risk assessment 

instruments in the community. The authors concluded that, in general, risk assessment 

instruments are available; however, most have been tested in only one setting. Therefore, further 

validation studies should be conducted on fall risk assessment instruments before any specific 

instrument can be recommended. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

A potential time point for risk assessment is in the emergency department (ED). Several 

researchers have examined the effect of fall- and injury-prevention interventions applied to 

patients who are discharged from the ED after a noninjury or nonserious-injury fall. The 

overarching goal of these studies is to evaluate the ability of comprehensive risk assessment 

followed by targeted interventions to prevent future falls and fall-related injuries. Several studies 

have successfully shown that screening followed by tailored management can decrease repeat 

falls.42, 90-94 Close and colleagues42 found that fall rates were reduced by 61 percent and recurrent 

falls were reduced by 67 percent for patients who had comprehensive risk assessment after a fall, 

compared to individuals who received standard treatment. Davison and colleagues90 found a 36 

percent decrease in fall rates after 1 year for patients who received a multimodal intervention for 

fall prevention after being identified as a faller on admission to the ED. In addition, these 

researchers noted an increase in falls self-efficacy, which is a measure of an individual’s 

perception of their ability to manage situations where they are at high risk for falling – the higher 

self-efficacy, the more able a person is able to manage high risk situations. In a related study, 

Lee, Hurley, and colleagues91 conducted a randomized controlled trial to examine the impact of a 

personal emergency response system and found that there was no difference between treatment 

and control groups for self-efficacy or patient anxiety. The Lee and colleagues study is 

informative in that emergency contact alone was not sufficient to improve a patient’s belief in 

their ability to manage fall risk situations. Although no standardized instrument has yet been 

developed for use in the ED environment, the potential for the prevention of falls and related 

injuries in the community would be increased with the accurate identification of patients at risk 

for falls while they are in the ED. 

Automated risk assessment in the community setting. To date, a limited number of 

computer-based, community-based fall assessment instruments have been described. By far the 

most complex and integrated is the Fall Risk Assessment and Management System, which was 

developed by the Australia Family Practice Group for use in the community by family practice 

physicians.95 Fall Risk Assessment and Management System includes automated 

recommendations after the clinician executes a thorough patient assessment. Although this 

system appears promising, its efficacy has not yet been reported. 

Lord, Menz, and Tiedemann96 describe an electronic fall risk assessment instrument that 

provides a method to measure several risk factors, including vision, peripheral sensation, muscle 

force, reaction time, and postural sway. Although this instrument is thorough, it is meant for use 

by a physical therapist or a physician, nurse practitioner, or physician assistant for a focused fall 

risk assessment, rather than as a triage or screening tool. The novel aspect of this instrument is 

the comparison of the individual’s score to the normative scores for each of the assessments, 

which provides the clinician with an anchor and may facilitate improved screening over time. 

However, the predictive validity of this instrument has not been reported, and its use may be 

limited to a fall-prevention clinic. 

Another electronic fall risk assessment instrument, described by Dyer and colleagues,97 is an 

electronic checklist in a fall-prevention clinic. Unfortunately, the researchers concluded that the 

clinic itself was more successful than the instrument in identifying risk factors for falling, 

underscoring the reality that the implementation of an instrument without associated policy and 

procedure changes may have limited effect. 

The presence of these automated systems indicates that there is movement toward 

computerized fall risk assessment. Indeed, many clinical information systems have adapted 

paper-based assessment instruments for use in the acute care setting. However, the efficacy of 

8 
Fall and Injury Prevention

these systems has not been reported, and their effectiveness is likely to be constrained by the 

limits of the original instrument, the system in which they are placed, and the design team in 

ensuring that the automated instrument accurately reflects the original instrument. 

Prevention strategies in the community. To date, several reviews conducted to examine the 

evidence available to support practice in this area have identified the need for multimodal, 

interdisciplinary prevention programs; the need for more accurate risk assessment instruments; 

and the need for more research related to this complex and costly problem.11, 98-107

Cumming100 reviewed 21 trials and concluded that exercise programs were the most 

promising, and reduction of antipsychotic medications should be considered. However, 

Cumming also concluded that none of the reviewed research studies provided a definitive 

prevention strategy. Chang and collaborators99 conducted a similar review targeted at examining 

interventions for older adults in the community and found that multimodal assessments with 

targeted intervention reduced risk of falls by 37 percent, and that exercise interventions reduced 

fall risk by 14 percent. Hill-Westmoreland, Soeken, and Spellbring38 conducted a recent metaanalysis, including a sensitivity analysis, which identified an improved effect on fall prevention 

in the community when individualized management was added to exercise interventions. They 

concluded that exercise interventions were not sufficient in and of themselves, and interventions 

needed to be tailored to address individual risk factors. 

Researchers have explored several other individual prevention strategies, including fall 

prevention clinics, exercise interventions with leg strengthening (e.g., Tai Chi), vitamin D 

supplements, home visits for safety evaluations, cataract surgery, and cardiac pacing. Falls and 

balance clinics present a promising community-based solution to the problem of falls.108 Perell 

and colleagues109 found a 50 percent reduction in fall rates for patients who were screened at a 

clinic and who had tailored interventions applied; however, this study had no control group and 

the researchers did not report injury rates, so the results are tentative. Clinics such as these 

provide focused intervention planning for patients identified at risk for falling, but the success of 

such clinics is contingent upon accurate identification of high-risk patients. 

Identification of recurrent fallers via comprehensive screening followed by tailored 

interventions has been successful at reducing recurrent falls. Screening and intervention done in 

the ED reduced recurrent falls by 36 percent in one study,90 and a nurse-led intervention that 

provided home assessment and tailored interventions reduced recurrent falls by 38 percent in 

another study.110 Hogan and colleagues111 also evaluated tailored interventions for patients who 

had had a fall within the past 3 months. They found no significant differences between the 

intervention and control groups in fall rates or time to first fall; however, the intervention group 

had a longer time between falls (P = 0.001). However, the Hogan and colleagues study limited 

inclusion criteria to patients older than 65 years of age who had fallen in the past 3 months, and 

these two factors alone are likely insufficient to determine risk. These recent studies add to early 

work in the PROFET study, which found a 61 percent decrease in falls for patients who were 

identified in the ED and who had subsequent detailed risk assessment and tailored 

interventions.42

Exercise-related interventions are by far the most commonly studied individual community 

prevention strategy. Most of this research indicates that exercise is beneficial for patients, and 

some research demonstrates that exercise regimes that involve leg strengthening and balance 

training, such as Tai Chi, are most effective.112-122 Robertson and colleagues123 performed a 

meta-analysis of four studies that examined effects of home exercise programs. They found in 

the pooled effect analysis that both fall and injury rates decreased by 35 percent. Exercise in 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

conjunction with cognitive behavioral therapy, where patients are taught how to increase selfawareness about risky situations, has demonstrated promising results, including a longer time to 

first fall and decreased injuries.124 Unfortunately, this work did not demonstrate an effect on falls 

efficacy, fear of falling, or actual fall rates. More recently, balance training has been compared to 

general exercise, and results show that balance training can prevent falls in the nonfrail elderly, 

but not in the frail elderly.125 Lin and colleagues126 found that deployment of large scale Tai Chi 

training to the general community had mixed results. Luukinen and colleagues127 found a 

decrease in fall and injury rates with a targeted exercise program when compared to usual care, 

but the results were statistically significant only in a group that was not homebound—suggesting 

that early intervention may be more effective. Further research to explore interventions for 

homebound community dwellers, particularly for the very old and frail, will be important. 

Laboratory studies indicate that calcium and vitamin D reduce bone loss,128 and a growing 

body of work is examining the ability for vitamin D supplementation to prevent fractures in 

individuals who are vitamin D deficient. A meta-analysis performed by Bischoff-Ferrari and 

team129 revealed that larger doses of vitamin D supplementation (700–800 IU/deciliter) reduced 

the risk of fracture by up to 26 percent, whereas smaller doses of vitamin D (400 IU/deciliter) did 

not reduce fracture risk. However, research to date has been inconclusive, and larger, more 

recent studies have indicated that the use of vitamin D does not reduce fracture risk in the 

general community.130 On the other hand, vitamin D supplementation may be integral in 

preventing falls themselves:131 Recently, Latham and colleagues132, 133 demonstrated that vitamin 

D intake is an individual predictor for fall reduction, primarily by improving muscle strength. 

Bischoff-Ferrari and colleagues134 have also identified a reduction in fall risk for women, but not 

for men, using vitamin D supplementation. Although these results are promising, more research 

is required to identify best practice recommendations related to vitamin D deficiency screening 

and vitamin D supplementation or other bone-supporting medication regimes. 

Other researchers are exploring the ability for osteoporosis-prevention medications to reduce 

fracture risk.135 Sato and colleagues136, 137 reported that risedronate, an oral bisphosphonate for 

osteoporosis prevention, was effective at preventing fracture in older females, older males who 

have had a stroke, and older females with Alzheimer’s disease. A recent large study by 

McCloskey and colleagues138 (N = 5579) demonstrated a 20–29 percent decrease in clinical 

fractures in community-dwelling females older than 75 years with and without osteoporosis who 

were prescribed clodronate 800 mg daily. However, this study did not find a decrease in hip 

fractures. Recent reports of adverse side effects of large doses of bisphosphonates, including 

osteonecrosis of the jaw, indicate that further research is warranted and that patients should be 

monitored for side effects of these drugs. Other related fall prevention efforts include home 

assessment for risk factors with the implementation of safety devices such as handrails, nonslip 

surfaces on stairs, and removal of throw rugs.139-143 Researchers who conducted a recent 

randomized controlled trial found that thin-soled shoes were found to be the best type of shoe for 

patients, rather than running shoes, which have sticky soles.144 Research addressing syncoperelated falls indicate that cardiac pacing may be appropriate for individuals with syncope.145 

Summary of community-based research on falls and related injuries. In summary, 

authors of several reviews have examined the efficacy of community-based fall- and injuryprevention programs. These reviewers have indicated that individualized multimodal 

interventions are effective at reducing falls and related injuries in the community setting.105

However, multimodal interventions are not in place across primary care areas, which hinders 

their potential efficacy, and the aging community would likely benefit from large-scale 

10 
Fall and Injury Prevention

implementation of these proven preventive interventions. (See Evidence Tables 1 through 9 for 

individual study results.) 

Falls and Related Injuries in the Acute and Long-Term Care Settings 

Fall and related injury prevention is a major focus for both acute and long-term health care 

organizations. In 2005, the Joint Commission added the requirement for fall risk assessment and 

periodic reassessment as a National Patient Safety Goal in the acute care setting.54 The goal of 

this requirement is to ensure that all patients are screened for falls and thus seeks to reduce harm 

from falls. However, the outcome is unpredictable because fall and injury risk assessment 

instruments have shown inconsistent reliability and validity A more promising extension of this 

goal starting in 2006 and continuing forward is the additional requisite of implementing and 

evaluating a fall-prevention program.146 National compliance with these goals has the potential 

to significantly impact the problem of falls in the acute care setting. Efforts to enhance quality of 

care in the long-term care environment via improved reporting have the potential to reduce falls 

and related injuries in these particularly vulnerable patients; however, the successful 

implementation of fall-prevention programs will be necessary to improve the problem. 

Falls in the acute and long-term care settings have several possible consequences. Recurrent 

falls have been identified as contributing to increases in the length of stay (LOS) in elderly 

psychiatric patients.147 However, some research has suggested that LOS itself may be a predictor. 

A fall may also lead to a poorer quality of life because of fallophobia, a fear of future falls, 

which may itself contribute to fall risk.148 Injuries occur in between 6 and 44 percent of falls in 

the acute care setting.20, 21, 23 In the long-term care population, between 9 and 15 percent of falls 

result in injury, with approximately 4 percent of these falls resulting in fractures.149 Additionally, 

patients who have underlying disease states are more susceptible to injuries; for example, 

osteoporosis can increase the risk for fracture, and bleeding disorders can increase the risk for 

subdural hematomas.150 Moreover, fall-related injuries increase resource utilization: injuries 

from falls lead to increased LOS and an increased chance of unplanned readmission or of 

discharge to residential or nursing home care.151 Furthermore, inpatients who have incurred an 

injury due to a fall have approximately 60 percent higher total charges than those who did not 

fall or those who fell and did not sustain an injury.152 

Evans and colleagues,153 via the Joanna Briggs Institute, performed a systematic review of 

the evidence up to 1997 for fall and injury prevention in the acute care setting. They examined 

200 studies related to identification of predictors, risk assessment instrument development and 

testing, and fall- and injury-prevention interventions. Of these studies, only two were 

randomized controlled trials (RCTs). The trial by Tideiksaar and colleagues154 examined the use 

of bed alarms to notify staff when patients at high risk for falls got out of bed; however, this 

study had a sample size that was too small to identify an effect from using bed alarms. The other 

RCT examined the use of colored bracelets to identify patients at high risk for falls. Again, the 

study results were inconclusive.155 Evans and colleagues concluded that the fall risk assessment 

instruments available were not generalizable. However, they did not adequately compare the 

psychometric properties of the instruments in question; rather they evaluated research related to 

the implementation of such instruments, which was relatively weak up to that time. In addition, 

Evans and colleagues concluded that individual interventions were not more useful that any of 

the fall-prevention programs that might be developed at a particular institution for a specific 

subset of patients. However, recent research has seen a growing number of RCTs, which will 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

facilitate the ability to make stronger practice recommendations for this complex and challenging 

problem. 

For this review, research related to falls and related injuries in the acute and long-term care 

settings were identified and categorized as follows: risk factor identification, risk assessment 

instruments, and prevention strategies. Each category of research is discussed below. 

Acute care and long-term care risk factors. Factors associated with patients at risk of 

falling in the acute care setting have been explored extensively, particularly over the past two 

decades.17, 87, 156-160 Evans and colleagues161 conducted a systematic review of research and 

identified 28 risk factors for falling, including impaired mental status, special toileting needs, 

impaired physical status, and to some extent age and medications. Oliver and colleagues159

reviewed risk factor and risk assessment literature and identified five risk factors consistent 

across studies: unsteady gait, increased toileting needs, confusion, sedative-hypnotics, and 

history of falling. In the long-term care environment, risk factors are largely the same, with the 

addition of inability to transfer effectively162 and short-term memory loss.163 Although ability to 

transfer and short-term memory function might be characterized by unsteady gait and confusion, 

these items are expressly captured via the LTCMDS. 

Research has consistently demonstrated that multiple factors are associated with falling in 

elderly and hospitalized patients and that fall risk increases as the number of factors increases.98, 

153, 156-159, 164-166 Although increased age is a strong predictor of falling in the community, 

increased age has not always been identified as a predictor in the acute care setting. Some studies 

have found increased age to be a risk factor,17, 165 but others have found that increased age is not 

a factor in acute care.157, 167, 168 Comorbidities and impaired functional status may be more 

important predictors of falls and subsequent injury in this setting.150, 157 Recent work by 

Hendrich169 did not support the association between increasing age (older than 65 years) and 

increasing risk of falling in the inpatient environment. Instead, Hendrich and colleagues169 found 

that confusion was the most important risk factor associated with the risk of falling. Nevertheless, 

age must be considered when discussing injury associated with falls because often with age 

comes frailty. Several researchers have identified gender as a risk factor, with female gender 

being a stronger risk factor in the older population170 and male gender a stronger factor in the 

younger population.167, 169, 171 A recent retrospective analysis by Krauss and colleagues170 found 

that altered mental status was not a factor in falls, but that patients in academic medical centers 

were more likely to fall. This research was limited because it did not control for patient acuity or 

staffing levels. 

Harwood and colleagues172, 173 reviewed the literature related to visual problems and falls and 

found that uncorrected visual impairment nearly doubled the risk of falling. Cardiovascular 

causes of falls derive predominantly from neurally mediated disorders (e.g., vasovagal syncope) 

and cardiac abnormalities (e.g., arrhythmias, infarction, valvular stenosis).174, 175 Time of day has 

also been implicated; Tutuarimia and colleagues176 identified a higher rate of falls on the night 

shift, but this is inconsistent with other research and may in fact be explained by staffing patterns. 

Association of falls to the lunar cycle has also been explored, but no association was found.177 

Vitamin D deficiency has been implicated as a risk factor for falls and fracture in the longterm care setting.178 In addition, elevated alkaline phosphatase and low serum parathyroid 

hormone have been identified as predictors for falls,179, 180 and anemia has also been 

implicated.181

A number of researchers are exploring the relationship between nurse-to-patient staffing 

ratios and an increase in the incidence of falls.20, 176, 182-184 Some of this work has identified an 

12 
Fall and Injury Prevention

inverse association between licensed nurse staffing ratios and fall rates (i.e., a higher proportion 

of nurses is associated with lower fall rates);176, 182, 184, 185 however, the overall the results are 

inconclusive.186 In addition, a growing body of research related to failure to rescue, defined as 

being “based on the premise that although deaths in hospitals are sometimes unavoidable, many 

can be prevented,”187-189 supports the inclusion of unanticipated physiologic events in the 

definition of falls since the patient’s safety issues should be addressed at all times. Other 

researchers examining nurse staffing ratios and fall rates suggest that fall rates are reduced by 

increasing the number of nurse aids rather than licensed nursing staff.190 This is potentially 

supported by recent work by Krauss and colleagues;191 of the fallers in their case-control study, 

85 percent of those in need of assistance or supervision with ambulation fell while not being 

supervised. 

Certain subgroups of patients have been identified at higher risk because of the inherent 

characteristics of their disease process or treatment modalities. These groups include geriatric, 

behavioral health, oncology, rehabilitation, stroke, and multiple sclerosis patients. In the 

behavioral health setting, fall rates range from 4.5 to 25 falls per 1,000 patient days.192, 193

Researchers have identified the typical faller in the behavioral health setting as a female with a 

history of falls; who was younger than 65 years of age; who was experiencing anxiety and 

agitation; and who was receiving a sedative, a tranquilizer, or a laxative.194 Irvin195 explored risk 

factors in the psychiatric setting and found that gait or balance problems and history of falls were 

the primary predictors. Although many of these characteristics are consistent with patients in the 

acute care setting, younger age and comorbidities such as depression and psychosis are often 

predictors in the behavioral health population.196-199 In addition, treatments specific to behavioral 

health patients are different than those in the acute care setting. For example, patients being 

treated for late-life depression are at risk for falling in the first weeks of using a tricyclic 

antidepressant and should be monitored closely while they are adjusting to the new medication.75

De Carle and Kohn200, 201 have described risk factors in behavioral health patients and have 

identified electroconvulsive therapy as a predictor. 

Patients in rehabilitation units are also at higher risk, likely because they have suffered 

neurological injuries such as stroke or head injury, which precipitate muscle weakness, impaired 

cognition, and impulsivity.202-205 In addition, these patients are being physically challenged, 

which places them in higher-risk situations and thus at greater risk for falling.206 

In the pediatric inpatient setting, fall rates range from 0 to 0.8 per 1,000 patient days.207

These rates are very low compared to adult inpatient and long-term care rates. The factors that 

limit the number of falls in this population are unclear, but may be related to increased 

supervision of pediatric patients via higher nurse-to-patient staffing ratios and the common 

practice of parents staying with pediatric inpatients. 

Injury risk factors in the acute and long-term care setting. In general, injury risk factors 

are similar across care areas. Vassallo and colleagues208 examined the risk factors associated 

with injury in a group of inpatient fallers and found that three factors were associated with 

injuries related to falls: (1) history of falls, (2) confusion, and (3) unsafe gait. In addition to these, 

Rothschild and colleagues134 identified physiological processes, such as increased bleeding 

tendencies and osteoporosis, as factors that increased risk for bleeding or fracture. The risk for 

medications or physiologic factors to precipitate injuries related to bleeding have been explored 

on a limited basis in the inpatient population. Contrary to results in the community,84 Stein and 

team209 found that hospitalized stroke patients who are anticoagulated are not at higher risk for 

injury than nonanticoagulated patients; however, this study was small and the issue warrants 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

further research. Bond and colleagues210 examined over a 4-year period the risk for bleeding 

injury among 1,600 patients who fell while hospitalized. These researchers found that half of the 

patients were on thrombotic therapy and that the incidence of fall-related intracranial hemorrhage 

was low, even in persons taking warfarin. The authors suggested that selection bias may be a 

factor because physicians might withhold anticoagulant therapy for patients who have a higher 

fall risk. More recently, Spector and colleagues211 performed a large study of nursing homes and 

found that 85 percent of fractures were caused by falls, and that those with epilepsy, those with 

agitation, and those taking anticonvulsants had the highest risk of sustaining a fracture if they fell. 

Table 2. Risk Factors for Falls and Injuries in Acute and Long-Term Care 

Intrinsic Risk Factors Fall Risk Injury Risk 

Demographics 

• Age Across ages Older 

• Gender Male Female 

Cognitive Function 

• Agitation Yes Yes 

• Anxiety Yes No data 

• Cognitive impairment Yes No data 

• Impulsivity Yes No data 

• Inability to follow instructions Yes No data 

• Short-term memory loss Yes No data 

Physical Function 

• Fall history Yes Yes 

• Fatigue Yes No data 

• Gait problems Yes No data 

• Impaired muscle strength Yes No data 

• Impaired physical functioning Yes No data 

• Toileting needs increased Yes No data 

• Postural hypotension Yes No data 

• Visual impairment Yes No data 

Physiologic Status 

• Alkaline phosphatase level elevated Yes No data 

• Anemia Yes No data 

• Parathyroid hormone deficiency Yes Yes 

• Prolonged bleeding time No data Yes 

• Vitamin D deficiency Yes Yes 

Comorbidities 

• Alzheimer’s disease Yes No data 

• Depression Yes No data 

• Diabetes Yes No data 

• Comorbidities in general Yes No data 

• Multiple sclerosis Yes No data 

• Parkinson disease Yes No data 

• Stroke Yes No data 

• Syncope Yes No data 

Medications 

• Anticoagulants No data Yes 

• Antiepileptics Yes No data 

• Chemotherapeutics Yes No data 

14 
Fall and Injury Prevention

Intrinsic Risk Factors Fall Risk Injury Risk 

• Laxatives Yes No data 

• Psychotropics Yes No data 

• Sedatives and hypnotics Yes No data 

Extrinsic Risk Factors Fall Risk Injury Risk 

Other Factors 

• Staffing Yes No data 

• Time of day Yes No data 

• Electroconvulsive therapy (in behavioral health) Yes No data 

• Being physically challenged (in rehab) Yes No data 

Acute care risk assessment instruments. Many tools have been developed to identify 

patients at highest risk for falling in the acute care setting.21, 159, 167, 169, 212-215 Perell and 

colleagues87 reviewed risk assessment tools and identified 6 functional assessment instruments 

and 15 fall risk assessment instruments developed by nursing. Vassallo and colleagues216

concurrently examined the predictive validity in the acute care setting of four commonly used 

risk assessment instruments (STRATIFY, Downton, Tullamore, and Tinetti) and found that the 

STRATIFY instrument was the easiest to use, was most effective of the four at predicting falls in 

the first week of inpatient admission (total predictive accuracy of 66.6 percent), but had the 

poorest sensitivity (68.2 percent). 

The most commonly reported risk assessment instrument is the Morse Falls Risk Assessment 

Tool.217 In 2002, O’Connell and Myers218 conducted psychometric testing with this tool on 1,059 

patients admitted to an Australian hospital. In this study, the Morse Falls Risk tool had a 

sensitivity of 83 percent and a specificity of 29 percent, but a positive predictive value of only 18 

percent. This resulted in a very high false-positive rate, with the tool identifying more than 70 

percent of patients who did not fall at high risk for falling. This research was confounded by the 

fact that the interventions were applied based on the instrument’s predictions; therefore, the 

predictive validity cannot be conclusively stated. The STRATIFY Falls Prediction tool also had a 

low positive predictive value (30 percent) and relatively low sensitivity (66 percent) and 

specificity (47 percent).212 

The Heinrich Falls Risk Model I is reported to be more robust (sensitivity, 77 percent; 

specificity, 72 percent) than either of the others, and the Hendrich Falls Risk Model II 

demonstrated even more improvement (sensitivity, 74.9 percent; specificity 73.9, percent; 

positive predictive value, 75 percent).169 The inclusion of a Get Up and Go test in the Heinrich II 

tool was the major change between version I and version II. The Get Up and Go test evaluates a 

person’s ability to rise from a chair in a single movement, which is an assessment method that 

has been explored in earlier fall-prediction research. It is surprising that the sensitivity and 

specificity of the tool increases only slightly with the addition of this factor, underscoring the 

complexity of predicting patient falls. In addition, prospective evaluation of the use of the 

Hendrich II instrument has yet to be reported. 

Several studies have tested the predictive validity of fall risk assessment instruments in 

relation to the judgment of nurses. Myers and Nikoletti219 concluded that neither the fall risk 

assessment instrument nor nurses’ clinical judgment acted as a reliable predictor. Eagle and 

colleagues220 compared the Functional Reach test, the Morse Falls Scale, and nurses’ clinical 

judgment in the rehabilitation and geriatric environment. This study also concluded that the two 

standardized assessment processes were no better at predicting falls than the clinical judgment of 

nurses. A limitation in both of these studies was that the evaluation occurred only at one time 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

point close to admission, which does not account for the variability of patient status throughout a 

patient’s hospital stay. 

In the domain of rehabilitation medicine, Ruchinskas221 compared structured assessments—

including the Mini-Mental State Exam, the Geriatric Depression Scale, the Functional 

Intervention Model, and the clinical judgment of physical and occupational therapists—on 

admission and discharge. This study concluded that the clinical judgment of therapists had a 

positive predictive power of 33 percent and a negative predictive power of 82 percent. However, 

the more accurate predictors of falling for the patients in their sample were a history of falls and 

presence of a neurological diagnosis. In the residential care environment, Lundin-Olson and 

colleagues222 found that clinical judgment can contribute to the accurate prediction of fall risk, 

but is not sufficient on its own as a valid predictor. 

Although fall-prediction research has been performed for two decades, it is clear that fall 

prevention is a complex problem that cannot be solved by risk assessment alone, hence the 

dissatisfaction with available risk assessment instruments. 

Long-term care assessment instruments. Lundin-Olson and colleagues223 developed the 

Mobility Interaction Fall Chart (MIF chart), which is an instrument based on a patients’ ability to 

walk and talk at the same time, the ability to maintain pace while carrying a glass of water, visual 

impairment, and difficulty concentrating. When the predictive validity of the MIF chart was 

evaluated, the researchers found that the chart was helpful only when used in conjunction with 

clinical judgment and knowledge of a patient’s history of falls, thus making the use of this 

instrument on its own limited.222 

The Downton instrument, originally developed in the community setting, characterizes risk 

by five factors: (1) increased dependency, (2) cognitive impairment, (3) increased number of 

physical symptoms, (4) presence of anxiety, and (5) presence of depression.224 This instrument 

has recently been prospectively evaluated in the long-term care setting with a reported sensitivity 

ranging from 81 to 95 percent and specificity ranging from 35 to 40 percent.225 Although the 

specificity is low, this instrument might provide a standardized measure to identify those at risk 

in the long-term care environment. 

Becker and colleagues162 have recently described an algorithm to assess fall risk in the longterm care setting, categorizing long-term care residents into three subgroups: (1) residents 

requiring assistance to transfer, (2) residents able to transfer with history of falls and requiring 

the use of restraints, and (3) residents able to transfer and with no history of falls but with urinary 

incontinence and visual impairment. The researchers found that the residents with the history of 

falls were at highest risk for falls, which is consistent with other research in this domain, but 

might be useful to tailor interventions and would warrant prospective evaluation. 

Acute care pediatric risk assessment instruments. Falls in the acute care pediatric setting 

are relatively rare; however, standardized assessment may be beneficial to reduce falls and 

injuries in this population. Graf207 has recently developed an instrument for acute care pediatric 

risk assessment. According to Graf, factors associated with pediatric falls include (1) seizure 

medication (odds ratio 4.9), (2) orthopedic diagnosis, (3) not using an IV (odds ratio 3.6), (4) 

physical/occupational therapy ordered, and (5) LOS (odds ratio 1.84 for every 5 days). This 

model has a sensitivity and specificity of 69 percent and 84 percent, respectively, and is being 

prospectively evaluated by the investigator with the hope that standardized assessment will 

facilitate reduction in these already-low rates. 

Automated risk assessment in the acute and long-term care settings. Recent national 

patient safety efforts highlight the promise of using informatics processes to manage patient 

16 
Fall and Injury Prevention

safety issues such as the management of patient falls. However, to date, most automated risk 

assessment techniques in the acute care setting are electronic versions of existing fall risk 

assessment instruments, with limited use of computerized decision support.167, 226, 227 Promising 

new work in data mining for fall prediction has demonstrated that use of the LTCMDS has the 

potential to use existing data to generate risk models for patients in this setting. 

Volrathongchai228 has recently explored the ability to use computerized data mining techniques 

to identify elderly residents of long-term care facilities who were at risk for falls. Although this 

work has not been prospectively evaluated, the research found that the use of these data mining 

techniques, in conjunction with nursing knowledge, had the potential to identify fallers. 

Acute and long-term care prevention strategies. The goal of any fall- and injuryprevention effort is to decrease adverse outcomes for the patients who are most vulnerable to 

falling. A beneficial consequence of fall- and related-injury-prevention programs is the potential 

to streamline resource use, with the added potential for decreased costs associated with this 

problem.229-231 To date, however, a ubiquitous fall- and injury-prevention strategy has not been 

identified for hospitalized patients, and implementation of multifaceted strategies is often 

difficult to introduce in the complex clinical environment.232

Several reviews have examined fall-prevention strategies in the acute and long-term care 

settings.98, 99, 153, 159, 233 Oliver, Hopper, and Seed234 examined 10 studies, including 3 RCTs and 7 

prospective studies with historical controls. Oliver and colleagues found that the pooled effects 

ratio was 1.0 (95% CI = 0.60–1.68), indicating that overall the interventions were not able to 

prevent falls. More recently, Oliver and colleagues235 have performed a meta-analysis of falland injury-prevention strategies and found a decrease in fall rates with multimodal intervention 

and a decrease in hip fractures with hip protectors in the long-term care setting. Agostini, Baker, 

and Bogardus98 conducted a review of the literature related to fall prevention for hospitalized and 

institutionalized older adults. This review did not pool the results, but examined the literature 

related to the use of armbands, bed alarms, and restraints for fall prevention, all of which will be 

discussed individually below. 

The use of physical restraints to prevent falls has been refuted because restraints limit 

mobility, contribute to injuries, and don’t prevent falls.236, 237 Agostini and colleagues98 examined 

literature related to fall prevention via restraint and side rail use, as well as fall rates when 

restraints were removed. Six studies found that restraints were associated with increased injuries, 

and restraint and side rail removal did not increase fall rates. Evans, Wood, and Lambert238 also 

examined the literature and found 16 studies that examined restraint minimization, concluding 

that restraint-minimization programs involving effective staff education can reduce injuries and 

do not increase fall rates. 

Several individual fall-prevention interventions have been examined, including the use of 

armband identification bracelets, exercise regimen, postfall assessment, bed alarms, toileting 

regimen, and vitamin D supplementation. Mayo and colleagues155 conducted a randomized 

controlled trial to examine if armbands would help identify high-risk patients in a rehabilitation 

unit and prevent falls in the high-risk group. The researchers, however, found that high-risk 

patients with a blue armband had higher fall rates than those without the armband. Despite 

widespread use, only one study from 1993 has examined bed alarms. Tideiksaar and 

colleagues154 found that bed alarms were an effective method for fall prevention (relative risk = 

0.32), but the intervention warrants further research. An associated intervention, a movement 

detector, has recently been developed. Kwok and colleagues239 studied movement detectors and 

found no difference between intervention and control groups. However, a pilot study examined 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

the use of a movement detection patch attached to the thigh, which alerts clinicians when elderly 

long-term care residents are moving about.240 Kelly and colleagues found a 91 percent decrease 

in falls during the 1-week testing period. Although this study quality was poor, the intervention 

might be suitable for select patients and bears further testing. Rask and colleagues224 and Taylor 

and colleagues225 evaluated the use of a fall-prevention program with a fall coordinator in the 

long-term care setting; they found that the control nursing homes had increases in fall rates over 

4 years, whereas the intervention nursing homes had stable fall rates during the same time period. 

Mulrow and colleagues241 examined the effects of a physical therapy exercise intervention 

for frail long-term care residents and found that fall rates increased in the intervention group. 

However, the intervention group in this study also showed an increase in general strength and a 

decrease in the use of assistive devices, making one wonder if the physical therapy intervention 

sought to decrease the use of assistive devices in inappropriate situations. Rubenstein and 

colleagues242 examined the ability for post-fall assessment to identify underlying factors that 

could be remedied to prevent further falls. Choi and colleagues243 examined the effect of Tai Chi 

in the long-term care setting and found a 38 percent decrease in falls in the Tai Chi group, but 

this was not statistically significant (relative risk = 0.62; 95% CI = 0.32–1.19). A larger study 

may demonstrate statistical significance. A more recent study by Nowalk244 reported no 

difference between groups who received strength training. The authors concluded that long term 

care residents may require individualized training, rather than group training. 

Bakarich, McMillan, and Prosser245 examined the impact of a toileting regimen for elderly 

confused patients with mobility problems in the acute care units of a large metropolitan teaching 

hospital. The researchers found that there were 53 percent fewer falls during shifts in which the 

risk assessment and toileting intervention was used, but that compliance with the assessment and 

intervention was difficult to maintain. More recently, Klay and Marfyak246 found that a 

continence specialist in the long-term care environment reduced falls by 58 percent. Vitamin D 

has also reduced falls in elderly females in the long-term care setting by up to 49 percent, and in 

both males and females by 25 percent.129, 134, 178, 247, 248 Further investigation of the use of vitamin 

D in the acute care and rehabilitation setting for fall and injury prevention is warranted. Jensen 

and colleagues249 examined the effect of exercise training on elderly residential care patients and 

found an increase in strength and balance, and a nonstatistically significant decrease in falls. This 

study was limited by its small sample size and unequal distribution of important risk factors such 

as Mini-Mental State Exam scores across groups. 

As with community interventions, tailored, multipronged prevention strategies are being 

shown to be more effective in acute and long-term care settings than individual interventions 

alone. Hofmann and colleagues250 used three concurrent interventions—staff education, an 

exercise program, and environmental modifications—for a frail elderly population. The 

concurrent use of these interventions decreased the fall rate by 38 percent and decreased the 

fracture rate by 50 percent. Haines and colleagues251 also examined a multipronged intervention 

involving staff and patient education, an exercise program, and the use of hip protectors. 

Researchers found a 22 percent decrease in falls and a 28 percent decrease in injuries in the 

intervention group. 

One of the most promising studies by Jensen and her research team252 investigated the effects 

of a comprehensive fall risk assessment and tailored intervention program in the long-term care 

setting. The intervention included assessment via the Mobility Interaction Fall Chart, visual 

evaluation, medication evaluation, and delirium screening by all members of the care team—

physicians, nurses, and physical and occupational therapists. This research demonstrated that the 

18 
Fall and Injury Prevention

comprehensive assessment and tailored interventions reduced falls by 51 percent and injuries by 

77 percent over a 34-week period. Healy and colleagues253 also found a statistically significant 

reduction in falls (RR = 0.71) by applying a tailored plan of care to adult inpatients who were 

deemed at high risk for a fall based on having had a previous fall. In effect, this research used 

history of fall as a method to triage high-risk patients, who then received a comprehensive risk 

assessment with targeted interventions. This research did not demonstrate a decrease in injuries; 

however, further research using this technique will be useful. McMurdo, Millar, and Daly254

found up to a 55-percent reduction in fall rates in a group of 133 nursing home residents with 

comprehensive risk assessment and balance training, but these results were not statistically 

significant. A larger sample size would provide a better understanding of the effect of the 

intervention. 

Other research examining multimodal interventions have had mixed outcomes. A recent 

study by Vassallo and colleagues255 in long-term care facilities found a decrease in falls was 

nullified when the results were controlled for LOS. However, controlling for LOS removes the 

ability for LOS to be identified as a predictor, which may be the case for patients who stay 

longer in a hospital setting. Kerse and colleagues256 found that in a group of nursing homes, 

long-term care residents who were randomized to risk assessment followed by tailored 

interventions showed an increase in falls (incident rate ratio = 1.34; P = 0.018). Semin-Goossens, 

van der Helm, and Bossuyt257 evaluated the effect of a guideline with semistructured 

interventions and found that fall rates in high-risk neurology and medical patients were not 

reduced. The researchers attributed the failure of the program to resistance by nurses to changing 

attitudes toward falls with the statement that nurses did not find falls troublesome enough. 

However, the failure was more likely due to system issues, such as ability to implement and 

agreement with the guideline, and training issues, which are common with guideline 

implementation failures.258, 259 In addition, the Semin-Goossens guideline did not use a 

standardized risk assessment instrument, which might have made it difficult to identify patients 

at risk. Fonda and colleagues260 studied a multimodal process-improvement plan and found that 

after 3 years, fall rates were decreased by 19 percent and injuries were decreased by 77 percent. 

Furthermore, this effect was sustained with continued use of the multimodal intervention. 

Schwendimann and others261 found a moderate, but not statistically significant decrease in fall 

rates, and no change in injury rates after implementing an interdisciplinary fall-prevention 

program. Lane262 found no decrease in patient fall rates before and after implementation of a fallprevention program. Although the results of multimodal studies are conflicting, it is important to 

note that none of the studies of multimodal interventions—whether effective or ineffective 

results—controlled for staffing ratios or skill mix. 

An increasing number of studies are examining the prevention of injury in the acute and 

long-term care settings. Hip protectors have been evaluated in the long-term care environment 

since the early 1990s. Although early work found that hip protectors were effective in reducing 

hip fractures in the frail or osteoporitic elderly,263 more recent work indicates that compliance 

with using hip protectors is difficult to maintain, making recommendation for hip protector use 

conditional.264, 265 Ray and colleagues266 examined the ability of a 2-day staff safety education 

plan to reduce serious fall-related injuries and found that this intervention was not effective, but 

the result may have been confounded by lack of staff compliance with the safety plan. (See 

Evidence Tables 1 to 9 for individual study results.) 

Summary of acute and long-term care falls and related injuries. In summary, fall 

prevention in the acute and long-term care settings is a complex and demanding problem with 

19 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

multiple patient types and risk factors to manage. Standardized risk assessment with multimodal 

tailored interventions appears to be the most successful method of prevention; however, 

implementation of comprehensive interventions across care settings can be challenging. Further 

research toward overcoming barriers to implementation, guideline adherence, staffing ratios, and 

tailored interventions for newly identified risk factors such as vitamin D deficiency and anemia 

are warranted. Furthermore, research must be conducted on a larger scale to demonstrate 

generalizability and to be able to translate evidence into practice. 

Evidence-Based Practice Implications 

Screening for fall and injury risk should be performed across settings. In the community, all 

patients older than 65 years should be screened, and in the home care, acute care, and long-term 

care settings, patients of all ages should be screened. Screening needs to include injury risk, not 

just fall risk. The most effective interventions are multimodal ones that address specific areas of 

risk and work with interdisciplinary fall-prevention teams. 

In the community, screening can take place with a general annual physical exam or other 

routine health care visit. A standardized risk assessment tool should be used, such as the Tinnetti 

screening tool, which has the highest sensitivity and specificity for use in the community, but 

screening for injury risk must be included. If a patient is seen in an emergency room because of a 

fall, evidence suggests that focused fall and injury risk evaluation is warranted, especially if the 

patient is to be discharged home, i.e., the discharge prescription should include a focused fall risk 

assessment by the primary care provider or by a fall-prevention clinic. Tailored interventions for 

elderly community dwellers can decrease fall rates. Interventions that have had the most success 

in the community include exercise interventions with leg strengthening and balance training (e.g., 

Tai Chi), medication adjustment, management of cardiac-related syncope, effective diabetes 

management, management of vitamin D deficiency, and home safety modifications. Interventions 

to prevent injury in the community include calcium with vitamin D for fracture prevention, and 

additional fall precautions and increased screening for patients on anticoagulant therapy. 

In the acute and long-term care settings, screening should be carried out using a standardized 

assessment tool for all patients. The Morse tool is the most commonly used in the acute care 

setting, but it does not screen for injury risk. In the long-term care setting, the LTCMDS may be 

an effective screening tool. In both acute and long-term care, effective interventions are 

multimodal and include medication adjustment, environmental adjustment, alarm devices, staff 

safety education, calcium and vitamin D, exercise interventions, and treatment of other 

underlying disorders. Interventions to prevent injury in the acute and long-term care settings 

include limiting restraint use, lowering bedrails, using hip protectors in long-term care, calcium 

with vitamin D, and possibly bisphosphonates in long-term care. Across the health care 

continuum, effective interventions have been identified, but their use is not ubiquitous. 

Research Implications 

In the community setting, identification of the best timing for screening and reassessment is 

needed. Identification of methods to build fall- and injury-prevention programs in the community 

is needed to guide policymakers. In the acute and long-term care settings, large multisite 

intervention studies that use multimodal interventions tailored for individual risk factors and that 

control for comorbidities, acuity, staffing, and other environmental factors are needed. Cost20 
Fall and Injury Prevention

effectiveness studies to characterize the impact of fall- and injury-prevention programs are 

needed in the acute and long-term care settings. 

Recommendations From Evidence-Based 

Practice and Research Implications

1. Recommendations for screening and assessment 

• Fall and injury risk screening should be performed in all settings. 

• All patients who fall should receive a comprehensive postfall assessment. 

• Methods for computerized screening and followup should be explored. 

Table 3. Recommendations for Screening and Assessment 

Evidence-Based Practice Recommendations Research Implications 

Community: 

• Screen all patients over 65 during routine or other 

visit. 

• For patients who screen positive, refer to fall-injury 

prevention clinic for focused fall-injury risk 

assessment, if available. 

• Examine risk factors related to race and gender. 

• Identify barriers to widespread screening. 

• Examine barriers to establishment of fall-injury 

prevention clinics. 

• Use a standardized risk assessment tool, such as 

Tinetti’s 9-item screening tool for (1) mobility, (2) 

morale, (3) mental status, (4) distance vision, (5) 

hearing, (6) postural blood pressure, (7) back 

examination, (8) medications, and (9) ability to 

perform activities of daily living (ADLs). 

(Note: This tool does not overtly assess for injury risk.) 

• Validate risk assessment instruments across culture, 

race, and language. 

• Examine predictive validity of injury risk factors such 

as antiplatelet therapy, bleeding disorders, vitamin D 

deficiency, and chronic subdural hematomas. 

• Develop instruments for patient self-assessment for 

fall and injury risk. 

• For patients > 65 years who present to the emergency 

department (ED) with a fall, refer to primary care 

provider for focused fall-injury risk assessment. 

• Examine the effect of identification in the ED using 

large, multicenter randomized controlled trials. 

• Identify barriers to widespread adoption. 

Evidence-Based Practice Recommendations Research Implications 

Home Care and Long-Term Care: 

• Screen patients of all ages. • Validate home care assessment instruments. 

• Use a standardized risk assessment tool, such as 

Tinetti’s 9-item screening tool. 

• Examine predictive validity of Long Term Care 

Minimum Data Set. 

• Reassess at regular intervals. • Examine best timing for reassessment in home care 

and long-term care. 

Evidence-Based Practice Recommendations Research Implications 

Acute Care Setting: 

• Screen patients of all ages. • Develop and validate instruments for subgroups. 

• Use a standardized risk assessment instrument such 

as the Morse, Hendrich II, or STRATIFY tools. 

(Note: These tools do not assess for injury risk.) 

• Validate instruments in multiple settings. 

• Explore predictive validity of physiologic factors such as 

low creatinine clearance, vitamin D deficiency, and 

anemia. 

• Assess for injury risk for patients with injury risk • Validate instruments that assess for injury risk. 

factors such as low BMI, frailty, osteoporosis, vitamin 

D deficiency, and antiplatelet therapy. 

• Reassess patients at regular intervals. • Examine the best timing for reassessment. 

21 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

2. Recommendations for interventions in the community setting

• Apply multimodal interventions as identified by risk assessment. 

• Participate in national reporting activities such as ANA–NDNQI. 

• Examine the use of computer-based guidelines in all settings. 

Table 4. Recommendations for Community Setting 

Evidence-Based Practice Recommendations Research Implications 

Fall Prevention: 

•Provide balance training with leg strengthening, such 

as Tai Chi. 

• Examine effect of starting balance training at younger 

age (i.e., 50 years). 

• Examine barriers to establishment and use of balance 

training centers. 

• Monitor medication side effects for patients older than 

65. 

• Identify medications with minimal side effect profiles 

for patients older than 65. 

• Limit medications to fewer than four, if possible. • Examine medication dosing for groups of medications. 

• Monitor and treat calcium and vitamin D deficiency. • Examine factors related to calcium and vitamin D 

metabolism in relation to muscle function. 

• Manage underlying disorders such as cardiac-related 

syncope, diabetes, and vision problems (e.g., 

cataracts). 

• Explore factors to manage groups of disorders. 

• Explore other diseases that may predict falls. 

•Provide home safety modifications. • Explore barriers to home safety modification. 

•Educate about use of thin-soled shoes (not running 

shoes). 

•Provide education about how to manage risky 

situations. 

• Further explore shoe type for specific patient groups. 

• Explore fall prevention self-management strategies. 

Injury Prevention: 

• Monitor for calcium and vitamin D deficiency; provide 

supplements for fracture prevention. 

• Conduct large studies that control for comorbidities, 

age, and other factors to explore efficacy of hip 

protectors in the community. 

• Increase screening for patients on anticoagulant • Identify safety measures for bleeding-injury 

therapy, those with bleeding disorders, and for the frail 

and very old. 

• Use bisphosph

prevention. 

• Explore interventions for the very old and frail. 

onates for patients with documented 

osteoporosis. 

• Explore safety of long-term use of bisphosphonates. 

3. Recommendations for interventions in the acute and long-term care settings

• Apply multimodal interventions as identified by risk assessment. 

• Participate in national reporting activities such as ANA–NDNQI. 

• Examine the use of computer-based guidelines in all settings. 

• Large, multi-site randomized controlled trials that evaluate tailored interventions while 

controlling for organizational culture, staffing, comorbidities, acuity, and other factors are 

needed. Injury rates should be the primary outcome of interest, since fall-rate reporting 

may be an imprecise measure. 

• Characterize the cost effectiveness of bundles of tailored interventions. 

22 
Fall and Injury Prevention

Table 5. Recommendations for Acute and Long-Term Care 

Evidence-Based Practice Recommendations Research Implications 

Fall Prevention 

• Educate staff about safety care.

• Train medical team, including students and residents, 

for fall-injury risk assessment and postfall 

assessment.

• Examine impact of safety education across 

interdisciplinary team. 

• Use alarm devices. • Examine impact of alarms on caregiver satisfaction. 

• Monitor medication side effects and adjust as needed. • Examine effect of computerized decision support for 

medication management. 

• Adjust environment (e.g., design rooms to promote 

safe patient movement). 

• Examine cost effectiveness of environmental 

adjustments. 

• Provide exercise interventions (e.g., Tai Chi) for longterm care patients. • Examine usefulness of exercise interventions for 

acute care patients. 

• Provide toileting regimen for confused patients (e.g., 

check patients every 2 hours). 

• Study barriers to maintaining and sustaining 

monitoring activities. 

• Monitor and treat calcium and vitamin D levels for 

long-term care patients. 

• Examine effects of calcium and vitamin D 

management for acute care patients. 

• Treat underlying disorders such as syncope, diabetes, 

and anemia. 

• Examine constellations of disorders that might 

precipitate falls. 

Injury Prevention 

• Limit restraints use. • Identify methods to overcome barriers to restraints 

reduction. 

• Lower bedrails. • Study efficacy of environmental changes. 

• In addition to fall rates, monitor injury rates. • Establish fatal fall rates across settings. 

• Use hip protectors for geriatrics and long-term care. • Identify methods to overcome barriers to use of hip 

protectors. 

• Use floor mats. • Examine effect of safety flooring. 

• Monitor prothrombin time, international normalized 

ration (PT/INR) for patients at risk for falling. 

• Identify safety measures for bleeding-injury 

prevention. 

• Ensure postfall assessment. • Examine barriers to postfall assessment. 

• Use bisphosphonates for patients with documented 

osteoporosis. 

• Explore safety of long-term use of bisphosphonates. 

Conclusion 

Falls and related injuries are an important issue across the care continuum. National efforts in 

the community via Healthy People 2010, in the acute care setting via the Joint Commission’s 

National Patient Safety Goals, and in the long-term care setting via the Nursing Home Quality 

Initiative project have the potential to significantly reduce falls and related injuries. The growing 

number of randomized controlled trials related to fall-prevention efforts is promising. However, 

most of these studies have been carried out in the community and long-term care environments, 

with few randomized controlled trials evaluating fall- and injury-prevention measures in the 

acute care setting. As with other nursing-sensitive quality indicators, recent research 

demonstrating an association between fall rates and nurse staffing ratios needs to be more fully 

explored. In addition, further research needs to explore automated methods of assessing and 

communicating fall risk, better methods for risk identification, and the identification of 

23 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

prevention measures. Indeed, with coordinated efforts to apply the evidence to practice, the 

problem of falls might be managed more effectively. 

Search Strategy 

MEDLINE,® the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), and 

Cochrane databases from inception to March 2007 were searched for medical subject heading 

terms, both individual terms and combinations of the following: accidental falls, patient safety, 

medical errors, nursing-sensitive quality indicators, and fall prevention. In addition, references 

from relevant articles were searched using the snowball technique, as were archives of select 

nursing research and gerontology journals. The Related Links function in MEDLINE was also 

used to maximize the search strategy. Google, Google Scholar, and citations from identified 

articles were also searched for additional possible references. Articles related to occupational 

falls, sports-related falls, alcohol-related falls, and physical abuse-related falls were excluded. 

Articles that reported physiologic characteristics that are suspected to preclude falls but that did 

not examine falls or fall-related injuries as outcomes were also excluded because the causative 

effect on falls and fall-related injuries is, to date, inconclusive. Further, articles that were 

published in a foreign language were excluded. Two hundred and twenty seven articles were 

reviewed. Sixty-one of these were intervention research studies related to fall and injury 

prevention (32 from the community setting; 33 from the acute and long-term care setting). 

Author Affiliation 

Leanne Currie, D.N.Sc., M.S.N., R.N., assistant professor, Columbia University School of 

Nursing; e-mail: LMC2007@columbia.edu. 

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246. Klay M, Marfyak K. Use of a continence nurse 

specialist in an extended care facility. Urol Nurs. Apr 

234. Oliver D, Hopper A, Seed P. Do hospital fall 2005;25(2):101-2, 107-8. 

prevention programs work? A systematic review. J 

Am Geriatr Soc. Dec 2000;48(12):1679-89. 247. Bischoff HA, Stahelin HB, Dick W, et al. Effects of 

vitamin d and calcium supplementation on falls: A 

randomized controlled trial. J Bone Miner Res. Feb 

2003;18(2):343-51. 

235. Oliver D, Connelly JB, Victor CR, et al. Strategies to 

prevent falls and fractures in hospitals and care 

homes and effect of cognitive impairment: 

Systematic review and meta-analyses. BMJ. January 

13, 2007 2007;334(7584):82-8. 

248. Flicker L, MacInnis RJ, Stein MS, et al. Should older 

people in residential care receive vitamin d to prevent 

falls? Results of a randomized trial. J Am Geriatr Soc. 

236. Evans D, Wood J, Lambert L. Patient injury and 2005;53(11):1881-8. 

physical restraint devices: A systematic review. 

Journal of Advanced Nursing. 2003;41(3):274-82. 249. Jensen J, Nyberg L, Rosendahl E, et al. Effects of a 

fall prevention program including exercise on 

mobility and falls in frail older people living in 

residential care facilities. Aging Clin Exp Res. Aug 

2004;16(4):283-92. 

237. Vassallo M, Wilkinson C, Stockdale R, et al. 

Attitudes to restraint for the prevention of falls in 

hospital. Gerontology. Jan-Feb 2005;51(1):66-70. 

238. Evans D, Wood J, Lambert L. A review of physical 

restraint minimization in the acute and residential 

care settings. J Adv Nurs. Dec 2002;40(6):616-25. 

250. Hofmann MT, Bankes PF, Javed A, et al. Decreasing 

the incidence of falls in the nursing home in a costconscious environment: A pilot study. J Am Med Dir 

Assoc. Mar-Apr 2003;4(2):95-7. 

239. Kwok T, Mok F, Chien WT, et al. Does access to 

bed-chair pressure sensors reduce physical restraint 

use in the rehabilitative care setting? J Clin Nurs. 

2006;15(5):581-7. 

251. Haines TP, Bennell KL, Osborne RH, et al. 

Effectiveness of targeted falls prevention programme 

in subacute hospital setting: Randomised controlled 

trial. BMJ. Mar 20 2004;328(7441):676. 

240. Kelly KE, Phillips CL, Cain KC, et al. Evaluation of 

a nonintrusive monitor to reduce falls in nursing 

home patients. J Am Med Dir Assoc. 2002;3(6):377-

82. 

252. Jensen J, Lundin-Olsson L, Nyberg L, et al. Fall and 

injury prevention in older people living in residential 

care facilities. A cluster randomized trial. Ann Intern 

Med. May 21 2002;136(10):733-41. 

241. Mulrow CD, Gerety MB, Kanten D, et al. A 

randomized trial of physical rehabilitation for very 

frail nursing home residents. Jama. 1994;271(7):519-

24. 

253. Healey F, Monro A, Cockram A, et al. Using targeted 

risk factor reduction to prevent falls in older inpatients: A randomised controlled trial. Age Ageing. 

Jul 2004;33(4):390-395. 

242. Rubenstein LZ, Robbins AS, Josephson KR, et al. 

The value of assessing falls in an elderly population. 

A randomized clinical trial. Ann Intern Med. Aug 15 

1990;113(4):308-16. 

254. McMurdo ME, Millar AM, Daly F. A randomized 

controlled trial of fall prevention strategies in old 

peoples' homes. Gerontology. Mar-Apr 

2000;46(2):83-7. 

243. Choi JH, Moon JS, Song R. Effects of sun-style tai 

chi exercise on physical fitness and fall prevention in 

fall-prone older adults. J Adv Nurs. Jul 

2005;51(2):150-7. 

255. Vassallo M, Vignaraja R, Sharma JC, et al. The effect 

of changing practice on fall prevention in a 

rehabilitative hospital: The hospital injury prevention 

study. J Am Geriatr Soc. Mar 2004;52(3):335-9. 

244. Nowalk MP, Prendergast JM, Bayles CM, et al. A 

randomized trial of exercise programs among older 

individuals living in two long-term care facilities: 

The fallsfree program. J Am Geriatr Soc. Jul 

2001;49(7):859-65. 

256. Kerse N, Butler M, Robinson E, et al. Fall prevention 

in residential care: A cluster, randomized, controlled 

trial. J Am Geriatr Soc. Apr 2004;52(4):524-31. 

34 
Fall and Injury Prevention

257. Semin-Goossens A, van der Helm JM, Bossuyt PM. 

A failed model-based attempt to implement an 

evidence-based nursing guideline for fall prevention. 

J Nurs Care Qual. Jul-Sep 2003;18(3):217-25. 

262. Lane AJ. Evaluation of the fall prevention program in 

an acute care setting. Orthop Nurs. 1999;18(6):37-44. 

263. Lauritzen JB, Petersen MM, Lund B. Effect of 

external hip protectors on hip fractures. Lancet. Jan 2 

258. Rubinson L, Wu AW, Haponik EE, et al. Why is it 1993;341(8836):11-3. 

that internists do not follow guidelines for preventing 

intravascular catheter infections? Infect Control Hosp 

Epidemiol. 2005;26(6):525-33. 

264. O'Halloran PD, Cran GW, Beringer TR, et al. A 

cluster randomised controlled trial to evaluate a 

policy of making hip protectors available to residents 

of nursing homes. Age Ageing. Nov 2004;33(6):582-

8. 

259. Cabana MD, Rand CS, Powe NR, et al. Why don't 

physicians follow clinical practice guidelines?: A 

framework for improvement. JAMA. 1999;282:1458-

65. 265. O'Halloran PD, Murray LJ, Cran GW, et al. The 

effect of type of hip protector and resident 

characteristics on adherence to use of hip protectors 

in nursing and residential homes--an exploratory 

study. Int J Nurs Stud. May 2005;42(4):387-97. 

260. Fonda D, Cook J, Sandler V, et al. Sustained 

reduction in serious fall-related injuries in older 

people in hospital. Med J Aust. 2006;184(8):372-3. 

261. Schwendimann R, Buhler H, De Geest S, et al. Falls 

and consequent injuries in hospitalized patients: 

Effects of an interdisciplinary falls prevention 

program. BMC Health Serv Res. 2006;6(1):69. 

266. Ray WA, Taylor JA, Brown AK, et al. Prevention of 

fall-related injuries in long-term care: A randomized 

controlled trial of staff education. Arch Intern Med. 

Oct 24 2005;165(19):2293-8. 

35 
Evidence Table 1. Reviews Examining Fall-Prevention Interventions in the Community 

Source 

Safety Issue Related to Clinical Practice 

Design Type* Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) Weigand 200193 Fall and injury prevention in the community Literature Review Design: Review Outcomes: Fall rates Setting: Community Population: Emergency patients Assessment of

fallers & targeted interventions 

Falls: No definitive evassessment followed is effective for prevenrequired. 

Cumming 2002100 Fall and injury prevention in 

the community 

Literature Review 

Design: Review Outcomes: Fall rates 

Setting: Community Population: Older adults 

Multiple interventions; 21 trials reviewed 

Falls:

• Exercise programs • Reduction of antips

be considered. 

• No definitive preven

Gillespie 2003104 Fall and injury prevention in 

the community 

Metaanalysis Design: Systematic 

Review Outcomes: Fall rates

Setting: Community Population: 21,668 people 

Multiple interventions; 62 trials reviewed 

Falls: Multimodal, inteprograms are most sRisk Assessment: Neassessment instrume

36 

Chang 200499 Fall and injury prevention in 

the community 

Metaanalysis Design: Review Outcomes: Fall 

rates

Setting: Community Population: Older 

adults

Multiple interventions; 40 trials reviewed 

Falls: Multimodal assintervention reduced and exercise interven14 percent. 

HillWestmoreland 200538 Fall and injury prevention in the community Meta- analysis Design: Meta- analysis Outcomes: Fall 

rates

Setting: Community Population: Older adults in long-term care setting 

Multiple interventions; 12 studies reviewed 

Falls: Decrease in falmanagement added t

Stevenson 2005135 Fall and injury prevention in 

the community 

Systematic Review 

Design: Systematic review Outcomes: Fracture, vertebral and nonvertebral 

Setting: Community Population: Older women at risk for fracture 

Review of calcium, vitamin D, and bisphosphonates 

Fractures: 

• Calcium, with or wit

fractures in patients 

• Calcium with vitami

in women not at ris

*

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stud

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case seri(17) Published guidelines, (18) Unpublished research, reviews, etc.
37 

Source 

Safety Issue Related to Clinical Practice 

Design Type

* Study Design, 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Shekele 200311 Fall and injury prevention in 

the community 

Metaanalysis Design: Meta- analysis 

Outcomes: Fall and injury rates

Setting: Community Population: Medicare recipients

Mulriple interventions 

Falls: Multifactorial fall prevfall rates
Evidence Table 2. Studies on Community-Based Fall-Prevention Screening with Tailored Interventions (listed chronologically) 

Source Safety Issue 

Related to 

Clinical 

Practice

Design 

Type† Study Design, Study Outcome 

Measure(s) 

Study Setting & Study 

Population 

Study 

Intervention

Key F

Close 199942 Tailored interventions for falls in the community RCT Design: RCT Outcomes: Fall rates, repeat fall rates, hospital admissions, Barthel Score (Max 100; higher score = higher functioning) Setting: Community Population: 397 patients ≥ 65 years who presented to an accident and emergency department with a fall Detailed medical and occupational- therapy assessment with referral to relevant services if indicated with 1 year followup. Falls: Decreased by 61 

were identified in the emwho had subsequent deand tailored interventioCI = 0.23–0.66; P = 0.0

Recurrent falls: Decrearatio = 0.33, 95% CI = 0Hospital admissions: D(odds ratio = 0.61, 95% Barthel score: Decline iin the control group (P 

Hogan 2001111 Tailored interventions for falls in the community RCT Design: Randomized controlled trial Outcomes: Fall rates, repeat fall rates, time between falls, emergency department visits, hospital admissions Setting: Community Population: 152 patients ≥ 65 years who had fallen within the previous 3 months In-home assessment in conjunction with the development of an individualized treatment plan, including an exercise program for those deemed likely to benefit. Cumulative number fall

differences (311 v. 241One or more falls: No spercent v. 72.0 percentMean number of falls: 4Repeat fall rates: No sigTime between falls: Lonintervention group (P < For multiple fallers at b

• Intervention group les• Time between falls lo

(P < 0.001) Emergency departmen

difference 

38 

Hospital admissions: N

† Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stud

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case seri(17) Published guidelines, (18) Unpublished research, reviews, etc.
39 

Source Safety Issue 

Related to 

Clinical 

Practice

Design 

Type† Study Design, Study Outcome 

Measure(s) 

Study Setting & Study 

Population 

Study 

Intervention

Key F

Lightbody 2002110

Tailored interventions for falls in the community 

RCT Design: RCT 

Outcomes: Falls, functional ability, emergency department visits, admission to hospital

Setting: Community Population: 348 consecutive patients ≥65 years who were discharged from emergency room after sustaining a fall 

Home assessment for medication, ECG, blood pressure, cognition, visual acuity, hearing, vestibular dysfunction, balance, mobility, feet and footwear 

Recurrent Falls: ReducFalls: Decreased falls in not statistically significaAdmissions and bed daadmissions and bed daand 69, respectively) thand 233, respectively). 

Nikolaus 2003141

Tailored interventions for falls in the community 

RCT Design: RCT

Outcomes: Number of falls, compliance with recommendations 

Setting: Patients identified in universityaffiliated geriatric hospital; intervention carried out in patients’ homes Population: 360 patients showing functional decline, especially in mobility, admitted to a geriatric hospital (mean age 81.5 years) 

Comprehensive geriatric assessment followed by diagnostic home visit and home intervention or a comprehensive geriatric assessment with recommendations 

Falls: Intervention groufalls than control group 0.69, 95% CI = 0.51–0.Falls: For subgroup wit

year, there was a 37 pe(incident rate ratio = 0.6

Nitz 2004108

Tailored interventions for falls in the community 

RCT Design: pilot 

RCT Outcomes: Fall rates, balance measures 

Setting: Australia; academic medical center Population: 73 adults (92 percent female) ≥

65 yrs 

Balance training sessions once a week for 10 weeks 

Falls: Intervention and showed reduction in falbetween groups. Balance measures: Impgroup. 
40 

Source Safety Issue 

Related to 

Clinical 

Practice

Design 

Type† Study Design, Study Outcome 

Measure(s) 

Study Setting & Study 

Population 

Study 

Intervention

Key F

Davison 200590

Tailored interventions for falls in the community 

RCT Design: RCT 

Outcomes: Fall rates, number of fall-related admissions, LOS, balance 

Setting: Accident & emergency departments in a teaching hospital and associated general hospital in the United Kingdom Population: 313 cognitively intact patients ≥ 65 years with fall or fall-related injury and at least one additional fall in preceding year 

Multimodal postfall assessment, including medical, physiotherapy, and occupational therapy evaluation 

Falls: 36 percent fewer group (relative risk = 0.Proportion of fallers: 65 intervention group contwith 68 percent in the c= 0.95, 95% CI = 0.81–Hospital admissions: Nand hospital admissionbetween groups. Hospitalization: Duratiowas reduced (mean diffdays, 95% CI = 0.1–7.6Activities-specific balan

Improved in the interve

Perell 2006109

Tailored interventions for falls in the community 

Pretest posttest design 

Design: Pretest, post-test Outcomes: Falls, repeat falls 

Setting: Urban Los Angeles – Veterans Affairs System Population: 120 elders referred to the clinic. Gender not reported. 

Screening following by tailored interventions at falls clinic 

Falls: Reduction of tota141; P = 0.0002). Incre12.5 percent patients. Mean fall rates: Reduct4.1;post = 2.0). Repeat falls: Reduction percent; post = 51 perc
EvidenceTable 3. Studies Examining Exercise-Related Interventions in the Community (listed chronologically) 

Source 

Safety Issue Related to Clinical Practice 

Design Type‡ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Reinsch 1992124

Exerciserelated interventions for fall prevention in the community 

RCT Design: Fourarm RCT 

Outcomes: Fall rates, time to first fall, injury rates 

Setting: 16 senior centers in Orange County, California Population: 230 older adults who were participants at senior centers 

Exercise in conjunction with cognitive behavioral therapy for safety self-awareness 

Falls: No effect on fall of falling. Time to first fall: LongeInjuries: Decreased injrelatively high percentaat least one fall, only 7community-residing eldattention. 

Province 1995115

Exerciserelated interventions for fall prevention in the community 

Metaanalysis Design: Preplanned metaanalysis of 7 

RCTs Outcomes: Time to each fall (fallrelated injury) by self-report and/or medical records 

Setting: Two nursing homes and five community sites Population: Patients ages 60–75, ambulatory, cognitively intact 

Exercise training one area or more of endurance, flexibility, balance platform, Tai Chi (dynamic balance), and resistance 

Falls:

• Fall rates decreased 

exercise (odds ratio 0.99). 

• Fall rates decreased 

plus balance training CI = 0.70–0.98). 

41 

Injuries: Patients who increase in injurious fadetect this outcome. 

Wolf 1997120

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT

Outcomes: Frailty indicators, occurrence of falls 

Setting: Community Population: 200 men and women ≥ 70 

years

Tai Chi, computerized balance training, or education 

Multiple falls: Risk of m47.5 percent 

‡ Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stud

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case seri(17) Published guidelines, (18) Unpublished research, reviews, etc. 
42 

Source 

Safety Issue Related to Clinical Practice 

Design Type‡ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Steinberg 2000143

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

with four armsOutcomes: Selfreported slips, trips, or falls 

Setting: Community, Australia Population:252 active, community-dwelling Australians ≥ 50 yrs. 

Education re: fall risk factors, strength/balance exercises, home safety advice, medical evaluation 

Falls: 30 percent reduc0.70 (95% CI = 0.48–1Slips: 58 percent reduc0.42 (95% CI = 0.29–0Trips: 64 percent redu0.36 (95% CI = 0.26–0

Rubenstein 2000116

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Muscle strength, endurance, mobility, balance, fall rates 

Setting: Communityliving men Population: 59 men ≥

65 years with specific fall risk factors 

90 min. exercise sessions 3x/week Focus on increased strength and endurance, improving mobility and balance 

Falls:

• Exercise group had l

nonexercisers when activity level (6 falls/16.2 falls/1,000 hour

• Total number of falls 

Strength: Exercise achon hip or ankle strengtphysical functioning. 

Robertson 2002123

Exerciserelated interventions for fall prevention in the community 

Metaanalysis Design: Meta- analysis of four 

studies Outcomes: Fall rates, injury rates 

Setting: Community setting: nine cities and towns in New Zealand Population: 1,016women and men ages 65 to 97 

Muscle strengthening and balance retraining exercises designed specifically to prevent falls 

Falls and injuries: Fall 

by 35 percent; no diffe• Fall rate incidence ra

CI = 0.57–0.75 

• Participants reporting 

had a higher fall rate 1.64–3.34). 

• Injury rate IRR = 0.65

Barnett 2003 113

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Fall rates, balance, muscle strength, fear of falling 

Setting: Community, South Western Sydney, Australia. Population: 163 subjects ≥ 65 years 

identified as at risk of falling using a standardized assessment screen by general practitioner or physical therapist 

Weekly group exercise program with ancillary home exercises over 1 year 

Falls: Fall rates decreaexercise group (IRR = 0.99). Balance measures: ImOther measures: No din strength, reaction timon Short-Form 36, PhyElderly or fear of falling
43 

Source 

Safety Issue Related to Clinical Practice 

Design Type‡ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Wolf 2003122

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Time to first fall, fall rates, balance 

Setting: 20 congregate living facilities in the greater Atlanta area Population: 291 women and 20 men ages 70 to 97 who were transitioning to frailty 

Intense Tai Chi exercise program or wellness education program 

Falls: Fall rates decreano statistical difference risk = 0.75, 95% CI = 0

Clemson 2004 114

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Fall rates 

Setting: Community Population: 310 men and women ≥ 70 years who had had a fall in the previous 12 months or were concerned about falling 

Occupational therapy home visits, lower-limb balance and strength training, environmental safety education 

Falls:

• 31 percent reduction 

(relative risk = 0.69, 0.025). 

• For men alone, 68 p

(relative risk = 0.32, 

Morgan 2004140

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Falls

Setting: CommunityPopulation: 294 men and women ≥ 60 years who had either a hospital admission or bed rest for 2 days or more within the previous month 

Exercise sessions lasting 45 minutes, including warm-up and cool-down, 3 times a week for 8 weeks (24 sessions) 

Falls:

• 49 percent reduction 

low baseline physica

• 3.5 times increase in 

baseline physical fun

Suzuki 2004118

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Fall rates 

Setting: Community, Japan Population: 52 elderly Japanese women 

Exercise intervention—home and community center 

Falls: Fall rates decrea(13.6 percent v. 54.5 p
44 

Source 

Safety Issue Related to Clinical Practice 

Design Type‡ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Li 2005112 Exerciserelated 

interventions for fall prevention in the community 

RCT Design: RCT 

Outcome: Fall rates, functional balance, physical performance, fear of falling 

Setting: Community in Portland, Oregon Population: 256 physically inactive elders ages 70 to 92 

Tai Chi or stretching 3x/week for 6 months 

Falls: 55 percent redugroup (relative risk = 0

Fewer falls in the Tai Cstretch = 73; P = 0.007vs. stretching = 46 per

Injuries: Fewer injuriouvs. stretching = 18 per

Lord 200588 Exerciserelated 

interventions for fall prevention in the community 

RCT Design: RCT 

Outcome: Fall rates

Setting: Community in Australia Population: 620 people ≥ 75 years

Interventions to maximize vision and sensation or brief advice or usual care

Falls: The rate of falls similar in the three groInjuries: The rate of injperiod were similar in t

Faber 2006125

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Falls, mobility, physical performance, and self-reported disability 

Setting: 15 homes for the elderly in Amsterdam, The NetherlandsPopulation: 287 elderly men and women (mean age +/- standard deviation, 85+/-6yrs) 

20-week exercise program of balance training inspired by Tai Chi or daily mobility activities or control 

Falls: Fall incidence ratraining group (2.4 fallmobility activities grou(2.5 falls/yr), but not stFor frail subjects: Risk exercise groups increa(hazard ratio = 2.95; 9

For pre-frail subjects: decreased by 61 perce95% CI = 0.18–0.88). 

Lin 2006126 Exerciserelated 

interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Falls, fall-related injuries, related functional outcomes 

Setting: 6 rural villages in Taiwan: 2 villages received intervention, 4 villages acted as controls Population:1,200 men and women ≥ 65 years screened; 88 participants 

Tai Chi training plus fallprevention education or fall-prevention education alone 

Falls: 50 percent greatamong the Tai Chi pra0.5; 95% CI = 0.11–2.significant. Tinetti Balance Scale: increased by 1.8 pointTinetti Gait Scale: Tai by 0.9 point (95% CI = Fear of Falling: No sigof falling. 
45 

Source 

Safety Issue Related to Clinical Practice 

Design Type‡ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Luukinen 2007127

Exerciserelated interventions for fall prevention in the community 

RCT Design: RCT 

Outcomes: Fall rates, time to first fall 

Setting: Community, home-dwelling Finnish Population: 555 older men and women (67 percent ≥ 85 years), most with history of recurrent falls or at least one mobility risk factor 

Suggestions for 

a program consisting of home exercise, walking exercise, group activities, self-care exercise, or routine care 

For all subjects: Falls:

• 12 percent decrease 

intervention group (h= 0.74–1.04). 

• 7 percent decrease i

statistically significan95% CI = 0.80–1.09)

For subjects not homFalls: • 22 percent decrease 

0.78, 95% CI = 0.64–

• 12 percent decrease 

ratio = 0.88, 95% CI 
Evidence Table 4. Studies examining physiologic interventions in the community (listed chronologically) 

Source 

Safety Issue Related to Clinical Practice 

Design Type§ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) Latham 2003132 Physiologic interventions to prevent falls in patients discharged from acute care to the community RCT Design: RCT Outcomes: Falls over 6 months Setting: Five hospitals in Auckland, New Zealand, and Sydney, Australia Population: 243 frail older people (53 percent female) One dose vitamin D 300,000 IU versus placebo OR 10 weeks of high- intensity home- based exercise versus attention lessons Falls: • Increase in falls for 

D as compared to psignificant (relative r0.79–1.59). • Decrease in falls for compared to attentiostatistically significa95% CI = 0.67–1.36

Injury: Patients in the 

increased risk of musratio = 3.6, 95% CI = 

Bischoff- Ferrari 2004178 Physiologic interventions to prevent falls and fall-related injuries in the community Meta- analysis Design: Meta- analysis of five RCTs Outcomes: Fracture Setting: Community Population: 1,237 participant in the five studies Vitamin D: Large dose = 700–800IU/d Small dose = 400 IU/d Falls: Compared with 

or placebo, vitamin D 22 percent (corrected = 0.64–0.92). Fracture: • Vitamin D 700–800I

fracture by up to 26 

• Vitamin D 400 IU/d 

risk. Numbers needed to t

need to be treated witperson from falling. 

46 

Sensitivity analysis of sample 10,001 – smarelative risk = 0.87, 95

§ Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stud

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case seri(17) Published guidelines, (18) Unpublished research, reviews, etc. 
47 

Source 

Safety Issue Related to Clinical Practice 

Design Type§ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Avenell 2005107

Metaanalysis Design: Metanalysis of 

RCTs or quasirandomized trials Outcomes: Fractures 

Setting: Community Poplulation: 7 trials; 18,668 participants 

Vitamin D or an analogue alone, or vitamin D with calcium, or Placebo, no intervention, or calcium 

Vitamin D or analogu

• No effect on hip frac

95% CI = 0.98–1.41

• No effect on vertebr

1.13; 95% CI = 0.50

• Any new fracture (re

= 0.91–1.09). 

Vitamin D or analogu

• Marginal reduction i

risk = 0.81; 95% CI 

• Marginal reduction i

(relative risk = 0.87; 

• No effect on vertebr• Calcitriol may be as

incidence of adverse 

Grant  2005130 Physiologic interventions to 

prevent falls and fall-related injuries in the community 

RCT Design: 

Factorial-design trial Outcomes: New low-energy fractures

Setting: Patients identified in 21 UK hospitals then treated at home after discharge Population: 5,292 

people ≥ 70 years (85 

percent female) with new low-trauma fracture, and who were mobile before that fracture 

800 IU vitamin D daily or 1,000 mg calcium daily or 800 IU vitamin D plus 1,000mg calcium daily or placebo 

Falls: No differences bratio = 0.94; 95% CI = Fractures:• No difference betwe

(hazard ratio = 1.02

• No difference betwe

and placebo. 

Sato 2005137 Physiologic interventions to 

prevent fallrelated injuries in acute care 

RCT Design: RCT

Outcomes: Vertebral factures, hip fractures

Setting: Community in JapanPopulation: 500 women ≥ 70 years with Alzheimer’s disease, vitamin D deficiency, and hyperparathyroidism 

Risedronate 2.5 with 1,000 IU vitamin D plus 1,200 mg calcium or placebo with 1,000 IU vitamin D plus 1,200 mg calcium 

Fractures: 72 percent the risedronate group CI = 0.13–0.59). 
48 

Source 

Safety Issue Related to Clinical Practice 

Design Type§ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

BischoffFerrari 2006134

Physiologic interventions to prevent falls and fall-related injuries in the community 

RCT Design: RCT 

Outcomes: Fall rates 

Setting: Community Population: 199 men and 246 women ≥ 65 years living at home 

700 IU of vitamin D plus 500 mg of calcium citrate malate per day or placebo 

Falls: 

• Vitamin D plus calci

falling in women by 0.54, 95% CI = 0.30

• Vitamin D plus calci

falling in women by women (odds ratio = 0.81). 

• Vitamin D plus calci

reduced the odds of = 0.93, 95 percent C

McCloskey 2007138 Physiologic interventions to 

prevent falls and fall-related injuries in the community 

RCT Design: RCT 

(double-blind) Outcomes: Hip and any clinical fracture

Setting: General community in South Yorkshire and North DerbyshirePopulation:5,579 women ≥ 75 years 

800 mg oral clodronate (Bonefos) or placebo 

Hip fracture: Slight incfracture in placebo gro95% CI = 0.71–1.47). Any fracture: 20 perceclinical fracture for pa(hazard ratio = 0.80, 9Osteoporosis-associa29 percent decrease i(hazard ratio = 0.71; 9
Evidence Table 5. Reviews Examining Fall Prevention Interventions in Acute and Long-Term Care (listed chronologically) 

Source 

Safety Issue Related to Clinical Practice 

Design Type

** Study Design, 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Evans 1998153 Fall and injury prevention in 

the acute care setting 

Literature Review 

Design: Review Outcomes: Fall rates

Setting: Acute care Population: Patients in acute care setting 

Multiple interventions; 200 studies reviewed 

Falls: Across settings, not more useful than faa specific subset of pa

Oliver 2000234 Fall and injury prevention in 

the acute care setting 

Metaanalysis Design: Systematic 

review Outcomes: Fall rates 

Setting: Acute care Population: Patients in acute care setting 

Multiple interventions; 10 studies reviewed 

Falls: Overall the intervprevent falls (pooled e0.60–1.68). 

Agostini 200198 Fall and injury prevention in 

the acute care setting 

Review Design: Review 

Outcomes: Fall rates 

Setting: Acute care Population: Patients in acute care setting 

Multiple interventions; two studies and one systematic review reviewed 

Falls: Interventions witfalls include identificatispecial flooring, and h

49 Oliver 

2007235 Fall and injury prevention in 

the acute care setting 

Metaanalysis Design: Systematic 

review Outcomes: Fall rates, fall-related fracture rate

Setting: Acute care Population: Patients in acute and long-term care setting

Multiple interventions; 43 studies included in meta-analysis 

Falls:

• Multimodal intervent

18 percent decrease 0.82; 95% CI = 0.68–

• Multimodal intervent

no significant effect o

Injuries:

• Hip protectors in long

a 33 percent decreasratio = 0.67; 95% CI 

• Multimodal intervent

no significant effect o

Other interventions: Inrecommend other inte

** Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stu

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case ser(17) Published guidelines, (18) Unpublished research, reviews, etc. 
Evidence Table 6. Studies Examining Environmental Interventions in Acute and Long-Term Care (listed chronologically) 

Source 

Safety Issue Related to Clinical Practice 

Design Type†† Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) Tideiksaar 1993154 Environmental interventions for fall prevention in acute and long-term care RCT Design: RCT Outcomes: Bed falls, staff attitudes toward the use of the system Setting: Geriatric evaluation and treatment unit Population: 70 patients (86 percent female), avg. age 84 years, at risk for falls Bed alarm system Falls: Bed alarms reduc

this was not statistically 0.32; 95% CI = 0.10–1The bed alarm system patients, families, and n

Mayo 1994155 Environmental interventions for fall prevention in acute and long-term care RCT Design: Blinded RCT Outcomes: Fall rates Setting: Geriatric care unit at university hospital Population: 70 patients at risk for falls Identification bracelet for patients at high risk for falls Falls: Identification brac

high-risk patients (haza0.8–2.4), but this was n

Kelly 2002240 Environmental interventions for fall prevention in acute and long-term care Pretest and post- test study Design: Crossover design for 1 week Outcomes: Fall rates Setting: Medicare unit of a skilled nursing facility Population: 47 patients at high risk for falls Movement detection patch attached to the thigh Falls: Fall rates decrea

patient days to 3.4 falls with movement detectio

50 

Kwok 2006222

Environmental interventions for fall prevention in acute and long-term care 

RCT Design: RCT

Outcomes:Physical restraints use, fall rates 

Setting: Two geriatric stroke rehabilitation wards in a convalescent hospital in Hong Kong Population: 180 geriatric patients perceived by nurses to be at risk of falls 

Bed-chair pressure sensor or control 

Falls: No difference in f

alarm group and controRestraints: No differencbetween chair alarm gr

†† Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stu

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case ser(17) Published guidelines, (18) Unpublished research, reviews, etc. 
Evidence Table 7. Studies Examining Physical Activity Interventions in Acute and Long-Term Care (listed chronologically) 

Source 

Safety Issue Related to Clinical Practice 

Design Type‡‡ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Mulrow 1994241 Physical activity 

interventions for fall prevention in acute and long-term care 

RCT Design: RCT 

Outcomes: Fall rates

Setting: 1academic nursing home and 8 community nursing homes Population:

194 frail long-term care residents 

Individually tailored one-onone physical therapy sessions or Friendly visits 

Falls: Fall rates incrgroup (79 versus 60

Nowalk 2001244 Physical activity 

interventions for fall prevention in acute and long-term care 

RCT Design: RCT 

Outcomes: Fall rates 

Setting: 2 long-term care facilities Population:110 elderly men and women (avg. age 84), capable of ambulating and able to follow simple directions 

Resistanceendurance with enhanced exercise or Tai Chi with enhanced exercise or enhanced exercise 

Falls and other outcto death, number of incidence of falls ditreatment and contr

51 

Choi 2005243 Physical activity 

interventions for fall prevention in acute and long-term care 

Nonrandomized trial 

Design: A quasiexperimental design with a nonequivalent control groupOutcomes: Fall rates 

Setting: Residential care facilities Population:68 fall-prone older adults, avg. age 77.8 years 

12-week Sunstyle Tai Chi exercise program 

Falls: 38 percent degroup, but not statis= 0.62; 95% CI = 0.

‡‡ Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stu

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case seri

(17) Published guidelines, (18) Unpublished research, reviews, etc. 
Evidence Table 8. Studies Examining Multimodal Interventions in Acute and Long-Term Care (listed chronologically) 

Source 

Safety Issue Related to Clinical Practice 

Design Type§§ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) Rubenstein 1990242 Multimodal interventions in acute and long-term care RCT Design: RCT with 2-year followup Outcomes: Fall rates Setting: Long-term residential care facility Population: 160 ambulatory subjects (avg. age, 87 years) Tailored interventions based on fall risk factors Falls: Patients in the 

percent fewer falls. Fall-related deaths: 1than controls by 2 yenot statistically signifi

Bakarich 1997245 Multimodal interventions in acute and long-term care Pretest, post-test Design: Pretest, post-test Outcomes: Fall rates Setting: 450-bed metropolitan teaching hospital Population: 2,023 patients ≥ 70 years Toileting regimen for at-risk patients (confused and having mobility problems) Falls: 53 percent less 

the risk assessment awas used. Lane 1999262 Multimodal interventions in acute and long-term care Pretest, post-test Design: Pre-post and comparative, descriptive design Outcomes: Fall rates Setting: Medical- surgical/critical care unit; large community hospital system Population: 292 older patients Fall-prevention program Falls: No decrease in 

between patients who implementation of the 

52 

McMurdo 2000254

Multimodal interventions in acute and long-term care 

RCT Design: RCT 

Outcomes: Falls and fractures 

Setting: Nursing home residents Population: 133 residents ≥ 84 years 

Assessment/ modification and seated balance exercise training program or reminiscence therapy 

Falls: 55 percent redwith exercise trainingsignificant (odds ratio 1.14). 

§§ Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stu

(before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) S(12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case seri(17) Published guidelines, (18) Unpublished research, reviews, etc. 
53 

Source 

Safety Issue Related to Clinical Practice 

Design Type§§ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Jensen 2002249

Multimodal interventions in acute and long-term care 

RCT Design: cluster 

RCT Outcomes: Fall rates, time to first fall, fall-related injuries 

Setting: 9 residential care facilities located in northern Sweden Population:439 residential care residents ≥ 65 years 

Comprehensive fall risk assessment and tailored interventions 

Falls: 51 percent redodds ratio = 0.49; 95Injuries: 77 percent reinjuries (adjusted odd0.06–0.94). 

Bischoff 2003247

Multimodal interventions in acute and long-term care 

RCT Design: Doubleblind RCT

Outcomes: Fall rates 

Setting: Long-stay geriatric care Population:122 elderly women (mean age, 85.3 years; range, 63–99 years) 

1,200 mg calcium plus 800 IU vitamin D daily or 1,200 mg calcium daily 

Falls: 49 percent redthat received calcium 14–71; 

P < 0.01). 

Hofmann 2003250

Multimodal interventions in acute and long-term care 

Pretest, post-test 

Design: Pretest, post-testOutcomes: Falls, fall-related fractures 

Setting: 120-bed nursing homePopulation: Frail elderly population 

Concurrent: Staff education, exercise, and environmental modifications 

Falls: 38 percent red0.0003). Injuries: 50 percent re

> 0.05). 

SeminGoossens 2003257

Multimodal interventions in acute and long-term care 

Pretest, post-test 

Design: Pretest, post-test pilot study Outcomes: Fall rates 

Setting: Academic medical center, 2 medical-surgical units Population: 2,670 patients 

Fall prevention guideline with semistructured interventions 

Falls: Fall rates in higmedical patients were 

Haines 2004251

Multimodal interventions in acute and long-term care 

RCT Design: RCT 

Outcomes: Fall rates, fallrelated injury rates, repeat fallers 

Setting: 3 subacute wards in rehabilitation and elder care hospital Population:626 men and women ages 38 to 99 years (avg. 80 years) 

Falls risk alert card, exercise, education program, and hip protectors or usual care 

Falls: 22 percent dec= 0.78; 95% CI = 0.5Injuries: 28 percent dintervention group, busignificant (P = 0.20)
54 

Source 

Safety Issue Related to Clinical Practice 

Design Type§§ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Healey 2004253

Multimodal interventions in acute and long-term care 

RCT Design: Cluster 

randomized trial Outcomes: Fall rates 

Setting: Elder care units and associated community units of a district general hospital in England Population: Patients deemed at high risk for falls received intervention 

Preprinted care plan for patients identified as at risk of falling and introduced appropriate remedial measures 

Falls: 29 percent decintervention group (re= 0.55–0.90, P = 0.00Injuries: No reduction 

Jensen 2004249

Multimodal interventions in acute and long-term care 

RCT Design: Clusterrandomized trial

Outcomes: Fall rates 

Setting: 9 residential care facilities in Sweden Population: 187 residents at high risk for falling ≥ 65 years 

Education, environment, exercise, drug review, postfall assessments, hip protectors 

Falls: Intervention ha

Kerse 2004256

Multimodal interventions in acute and long-term care 

RCT Design: Cluster 

RCT Outcomes: Fall rates 

Setting: Residential care homes Population:628 residents 

Risk assessment followed by tailored interventions 

Falls: 34 percent incrratio = 1.34; 95% CI 

Vassallo 2004208

Multimodal interventions in acute and long-term care 

Nonrandomized trial 

Design: Quasiexperimental Outcomes: Fall rates, injury rates, repeat fall rates 

Setting: 3 geriatric wards Population:825 consecutive geriatric patients 

Medication adjustment, environmental assessment, wristbands 

Falls:• 25 percent decreas

group, but not statisrisk = 0.75; 95% CI 

• No reduction in recInjuries: No reduction 

Flicker 2005248

Multimodal interventions in acute and long-term care 

RCT Design: 

Randomized, placebocontrolled, double-blind trial Outcomes: Falls and fall-related fractures

Setting: Multicenter study in 60 assisted living facilities and 89 nursing homes across Australia Population:625 residents (avg. age 83 years) with vitamin D deficiency 

Vitamin D 10,000 IU once, then 1,000 IU daily plus 600 mg calcium or placebo plus 600 mg calcium 

Falls: 27 percent decintervention group (in95% CI = 0.57–0.95)Injuries: 31 percent dstatistically significanCI = 0.40–1.18). 
55 

Source 

Safety Issue Related to Clinical Practice 

Design Type§§ Study Design, Study Outcome 

Measure(s) 

Study Setting & Study Population 

Study Intervention Key Finding(s) 

Klay 2005246

Multimodal interventions in acute and long-term care 

Pretest, post-test study 

Design: Pretest, post-test Outcomes: Urinary tract infections, pressure ulcers, and falls 

Setting: Connecticut long-term care center Population: 42 female residents who were incontinent or had urgency related to overactive bladder 

Individualized continence program 

Falls: 58 percent redtreatment with individ

Fonda 2006260

Multimodal interventions in acute and long-term care 

Pretest, post-test study 

Design: Pretest, post-test Outcomes: Fall rates, fall-related injuries

Setting: Long-term care setting, Australia Population: All patients admitted to the unit

Multistrategy approach: work practice changes, environmental/ equipment changes, staff education

Falls: 19 percent redfalls per 1,000 patien

0.001). Falls: 77 percent redfalls resulting in seriopatient days (0.73 v 0

Schwendimann 2006261

Multimodal interventions in acute and long-term care 

Design: Serial 

survey design Outcomes: Fall rates, fall-related injuries 

Setting: 300-bed urban public hospital Population: Adult patients in internal medicine, geriatrics, and surgery 

Interdisciplinary falls-prevention program 

Falls: Decrease in fa

significant (pre-9.0, pInjuries: No change i
Evidence Table 9. Studies Examining Interventions to Prevent Injury in Acute and Long-Term Care (listed chronologically) 

Source 

Safety Issue Related to Clinical Practice 

Design Type

*** Study Design, 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention 

Key Finding(s) Lauritzen 1993263 Physical interventions to prevent fall- related injuries in acute care RCT Design: RCT Outcomes: Hip fractures Setting: 10 of the 28 wards in a nursing home Population: 665 older patients (67 percent female) External hip protectors Fractures: 56 percent d

for patients wearing hip 0.44; 95% CI = 0.21–0

O'Halloran 2004264 Physical interventions to prevent fall- related injuries in acute care RCT Design: Cluster RCT Outcomes: Hip fracture Setting: 127 nursing and residential homes in Northern Ireland Population: 4,117 elderly residents Hip protectors, staff education Fractures: Slight increa

intervention group (adju95% CI = 0.77–1.43). Ray 2005266 Multimodal interventions to prevent fall- related injuries in acute care RCT Design: Cluster RCT Outcomes: Serious fall- related injuries Setting: 112 long- term care facilities Population: 10,558 residents ≥ 65 years, not bedridden Staff safety education plan with tailored interventions 

Injuries: 

• No difference in injury 

= 0.98; 95% CI = 0.8

56 

• 21 percent decrease 

with prior fall in facilitcompliance, but not s(adjusted rate ratio = 1.10). 

Sato 2005136 Physiologic interventions to 

prevent fallrelated injuries in acute care 

RCT Design: Double 

blind RCT Outcomes: Hip fractures 

Setting: Stroke unit at hospital in Japan Population: 280 male poststroke patients ≥65 years 

Risedronate 2.5 mg or placebo 

Fractures: 81 percent drisedronate group (rela0.04–0.89). 

Sato 2005137 Physiologic interventions to 

prevent fallrelated injuries in acute care 

RCT Design: Double 

blind RCT Outcomes: Hip fractures

Setting: Stroke unit at hospital in Japan Population: 187 female poststroke patients ≥ 65 years 

Risedronate 2.5 mg or placebo 

Fractures: 86 percent dthe risedronate group, significant (relative risk 1.2). 

***

 Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control stu

test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (1reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.