Fall Prevention Program Case Study


Beyond the Falling Star: Sustained Decreases In Falls and Injuries with Targeted Bed Exit Alarm, Staff Education Icons, and Patient Education Video

Subject Observation

San Francisco General Hospital experienced patient falls and injury rates above CALNOC benchmarks from Q1 2009 - Q3 2010 that appeared to be increasing. 


To decrease falls, falls with injury and falls with serious injury 40%.

Injury from falls while admitted to the hospital is the most common hospital acquired condition (HAC) in the U.S. accounting for more than 85% of all HAC from 2002 - 2010.1


Design:  Before-and-After Quality Improvement

Setting:  Academic Medical Center Public Level I Trauma Hospital

Sample:  Patient falls defined by CALNOC Units: One Med-Surg Acute Care for elders Behavioral Health (Pilot), Four Med-Surg units (Med-Surg), Four Med-Surg units + one Progressive Care + two Intensive Care units (All Acute)

Measures:  Monthly patient fall and injury rates per 1,000 patient days January 2009 - September 2010 (baseline) and follow up period October 2010 - June 2015

Phase I Interventions: Communication

  • Targeted night shift injury reduction (Cuttler, 2013).

  • Produced falls prevention movie shown to new clinical employees.
  • Hospital beds (VersaCare® bed) with built-in, three sensitivity exit alarms introduced October 2010.

  • Harm dashboard for improvement of communication of patient risk and harm.

  • Highlight fall risk patients during change of
    shift and transfer.

Phase II Interventions: Video

  • Addresses patient directly. 

  • Filmed in English, Spanish, Tagalog, Cantonese.

  • Shown to patients by trained hospital volunteers (Alexander et al., 2013).
  • Patient education video to communicate falls risk to the patient, patient advisor input. 

  • Written, produced and featuring hospital nurses, nurse assistants, rehab therapists, pharmacists, physicians, and housekeepers.

Phase III Intervention: Icons

  • Inspired by randomized controlled trial that included icons (Dykes et al., 2010)

  • "ICONtest" to reflect screen tool risk factors


Figure 1 (Red indicated statistically significant change from baseline)


  • Results are consistent with randomized controlled trial that demonstrated education as effective single intervention (Hill, 2015).

  • Integrated bed exit alarms help alert staff to frequent fallers before patient begins walking and may prevent or slow bed exit.

  • Falls rate decreases are comparable to Dykes et al. (2010) which reported no effect on injuries.
  • Pilot unit exceeded 40% reduction in all three outcome measures.

  • Night shift falls and injury rates have decreased since 2013.

  • Improvements have been sustained for more than four years.

  • Improvements meet or exceed CALNOC and America's Essential Hospitals Engagement Network benchmarks.
Multi-component Fall Prevention Program with communication and modern bed exit alarms have shown reductions in falls with moderate/major injury by up to 58%.2

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References »
  1. Attenello Frank J, et al. (2015) BMJ. 350:h1460.
  2. Cuttler S, et al. (2015, October). CALNOC