Improving falls in nursing homes: a post-fall huddle quality improvement project

  • Abstract
  • Keywords
  • References
  • PDF
  • Abstract

    Falls are one of the most common preventable health problems in adults 65 years and older (AHRQ, 2013). A fall in this population can have a devastating effect often leading to a significant change in morbidity or death. Adults in assisting living, nursing homes, and skilled facilities (SNF) have an increased risk of falling and having a subsequent fall due to an acute illness, weakness, or confusion. This makes individualizing a plan of care to prevent a secondary fall and identifying the root cause of falls within a facility imperative.

    In our agency, the fall rate is nearly triple that of the national benchmark. To address this problem, a Post-Fall Huddle project was implemented. The literature recommends and supports the practice of a post-fall assessment program in fall reduction to identify intrinsic and extrinsic fall risk etiologies. There was found to be a reduction in the absolute values of recurrent patient falls per quarterly reporting after the implementation of the post-fall huddle. The results also provided pertinent data that can be used for recommendations in future fall prevention for the SNF


  • Keywords

    Use about five key words or phrases in alphabetical order, Separated by Semicolon.

  • References

      [1] Agency for Healthcare Research and Quality (2013). Preventing falls in hospital: which fall prevention practices do you use? U.S. Department of Health and Human Services. Retrieved from

      [2] Anderson, C., Domato, E., Dolansky, M., and Jones, K. (2015). Predictors of serious fall injury in hospitalized patients. Nursing Research 24(3), 269-283).

      [3] Benoit, A., Carroll, D., Dykes, P., Hurley, A., & Middleton, B. (2009). Why patients fall acute care hospital? Can fall be prevented? Journal of Nursing Administration, 39(6), 294-304.

      [4] Bergey, M., Cunningham, J., Goldsack, J., & Mascioli, S. (2015). Hourly rounding and patient falls: what factors boost success. Nursing, 45 (2), 25-30.

      [5] Bellissimo, A., Chan, D., Grum, R., Moreland, J., O’neil, J., Richardson, J., & Shanks, S. (2003). Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology, 49 (2), 93-116.

      [6] Brown, C., Ecoff, L., Davidson, J., Gallo, A., Kim, S., Klimpel, K., & Wickline, A. (2013). Regional evidence-based practice fellowship program: Impact on evidence-based practice implementation and barrires. Clinical Nursing Research, 22(1), 51-69.

      [7] Belz, M., Bungum, L., Degelau, J., Flavian, P. L., Haper, C., Leys, K., Lundquist, K., & Webb, B. (2012). Institute for clinical systems improvement prevention of falls (acute care). 3d ed. Bloomington, MN: Institute for Clinical Systems Improvement. Retrieved from

      [8] Buchda, V. L., Hansen, C. M., Martyn, D. R., Pipe, T. B., & Wellin, K. E. (2005). Implementing evidence-based nursing practice. Urology Nursing, 25(5), 365-370.

      [9] Burns, M., Corrigan, B., Sanders, K., & Stetler, C. (1999). Integration of evidence into practice and the change process: fall prevention program as a model. Outcomes Management for Nursing Practice, 3(3), 102-111.

      [10] Cameron, L., Cummining, R., Gillespie, L., Kersey, N., Murray, G., & Robertson, M. (2012). Intervention for preventing falls in older people in nursing care facilities and hospitals. Cochrance Database of Systematic Reviews. Retrieved at

      [11] Center for Disease Control and Prevention (2015). Cost of falls among older adults. Retrieved at

      [12] Centers for Disease Control and Prevention (2015). Falls in nursing home. Retrieved at

      [13] Center for Disease Control and Prevention (2015). Older adult falls: get the fact.

      [14] Conley, D., & Lueckenotte, A. (2009). A study guide for the evidence-based approach to fall assessment and management. Geriatric Nursing, 30(3), 207-216.

      [15] Courtney, K. A. (2011). Implementing post-fall staff huddle. College of Nursing at ScholarWorks@UMass Amherst. Retrieved at

      [16] Daly, F., Oliver, D., & McMurdo, M. E. (2004). Risk factors and risk assessment tools for falls in hospital in-patient: a systematic review. Age & Ageing, 33(2), 122-30.

      [17] Draganecus, M., Grag, D., Johnson, J., Ratchliffe, S., & Strumpf, N. (2006). Psychometric properties of the post fall index. Clinical Nursing Research, 15(3), 157-176.

      [18] Evidence-Based Practice and Nursing Research: Avoiding Confusion. Retrieved at

      [19] Freedman, D., Pisani, R., & Purves., R. (2011). Statistics: Fourth edition. New York City: W.W. Norton.

      [20] Foukal, G. & Mantzorou, Marianna (2018). What are the major ethical issues in conducting research? is there a conflict between the research ethics and the nature of nursing? Health Science Journal Retrieved from

      [21] Fruh, S. & Rheaume, J. (2015). Retrospective case review of adults inpatient falls in the acute care setting. MedSurg Nursing, 25(4), 318-324.

      [22] Gallagher, E. B., Green, B., Margaret, M., Patrick, S., Robertson, B., & Spiva, L. (2014). Effectiveness of team training of fall prevention. Journal Nursing Care Quality, 29(2), 164-173.

      [23] Halm, M. (2009). Hourly rounds: what does the evidence indicate? American Journal of Critical Care, 18(6), 581-584.

      [24] Hatfield, B. (2007). The effects of post-fall assessment by an advanced practice nurse on Inpatient repeat fall rates. Clinical Nurse Specialist, 21(2), 112.

      [25] Heck, J. (2015). Accountability and teamwork: tools for a fall-free zone. Nursing Management, 46 (1), 40-45.

      [26] Hilsenbeck, J. and Trepan S. (2014). A hospital system approach at decreasing falls with Injuries and cost. Nursing Economic, 32(3), 135-141.

      [27] Hunskar, A., Phillips, L., & Yarno, D. (2008). Certified nursing aids and care assistant’s views falls: insight for creation and implementation of fall prevention programs. Journal of the American Medical Directors Association, 9, 168-172.

      [28] Hendrich, A. (2013). Fall risk assessment for older adults: the Hendrich ii fall risk model. Patient Safety Organization Ascenion Health.

      [29] Joint Commission (2015) National patient safety goals effective January 1 2015. Retrieved at

      [30] Kluge, A., Lecompte, M., Silva, A., & Snook, A. (2013). Improving staff reports of falls in assisted living. Clinical Nursing Research, 22 (4), 488-460.

      [31] Larrabee and Rosswurm. (1999). A model for change to evidence-based practice. Journal of Nursing Scholarship, 31(4), 317-322.

      [32] Lanch, H. (2010). The cost and outcome of falls: what’s a nursing administrator to do? Nursing Administration Quarterly, 34(2), 147-155.

      [33] National Fall Toolkit. (2014). Post fall huddle. U. S. Department of Veterans Affairs. Retrieved at

      [34] National Institute for Aging. (2017) Prevent Falls and Fractures. Retrieved at

      [35] Nelson, E. C., Batalden, P. B., & Godfrey, M. M. (2007). Quality by design: a clinical microsystem approach. Hoboken, NJ: John Wiley and Sons.

      [36] Penrod, J. (2013). Dissemination and implementation research. National Institute of Health. Retrieved from

      [37] Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins Publishers.

      [38] Tzeng, M. & Yin, C (2015). Patient engagement in hospital fall prevention. Nursing Economic, 33(6), 326-33.4

      [39] U.S. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Unintentional Injury Prevention. (2017). STEADI Stopping Elderly Accidents, Deaths, and Injuries: Older Adult Fall Prevention. Retrieved at




Article ID: 27533
DOI: 10.14419/ijans.v8i2.27533

Copyright © 2012-2015 Science Publishing Corporation Inc. All rights reserved.