It takes teamwork to prevent slips and falls

Hospitals tackle No. 2 cause of injury

It's easy to overlook the second-greatest cause of workplace injury because the incidents seem ordinary and isolated. But a comprehensive approach to prevention can reduce slips and falls in hospitals by about 50%, according to a study sponsored by the National Institute for Occupational Safety and Health (NIOSH).1

"It's a struggle to know how to fix it. It's not an easy fix," says Laurie Wolf, MS, CPE, a management engineer at BJC Healthcare in St. Louis, which participated in the study. After implementing interventions at its 13 hospitals, "Our workers' compensation claims are lower than they've ever been. They consistently decreased since 1997 when we put [the fall-prevention program] in place."

Decreasing the risk of employee falls has other benefits. You also reduce the likelihood of patient falls (a National Patient Safety Goal of the Joint Commission on Accreditation of Healthcare Organizations) and visitor injuries (a possible source of liability). "A well-maintained facility is going to take care of everybody," says Rich Schleckser, NEBOSH, ARM, CMIOSH, technical director at Liberty Mutual Insurance Company in Bedford, NH.

The Liberty Mutual Research Institute for Safety in Hopkinton, MA, participated in the NIOSH study, as did the Finnish Institute for Occupational Health, Johns Hopkins University, and the Veterans Health Administration.

Food services, parking/valet, and custodial/ housekeeping staff suffer the highest rate of slip, trip, and fall incidents per 100 staff in those job categories, says James Collins, PhD, MSME, epidemiologist/engineer and project officer for the Slips and Falls Prevention in Health Care Workers project at NIOSH in Morgantown, WV. Nurses have a lower rate, but they incur the largest number of workers' compensation claims due to the large number of nursing staff, he says.

A prevention program should correct hazards hospitalwide, he says. "The challenge in a healthy work force is that you have to provide a certain level of protection for everybody," he says.

Use multiple strategies

Be prepared to take an eclectic approach to slips and falls. "It's engineering, it's marketing, it's slip-resistant shoes, it's fixing all the cracks and slip hazards in the hospital, and, most importantly, keeping the floors clean and dry. It's a huge undertaking," says Collins.

Liberty Mutual also has been successful in helping hospitals reduce their slips and falls — by as much as 40%, says Schleckser, who works with employers as a loss prevention consultant. "When we direct focus away from general safety programming and aim directly at slips and falls, we do have significant impact," he says.

The first step is simply to put together a multidisciplinary task force, including maintenance, nursing, food service, housekeeping, security, and administrators, he says. You then can analyze falls as part of three broad categories: inside the facility, outside in the parking lot and entryways, and on stairs.

The NIOSH study found that about a third (36%) of same-level incidents occurred because of "floor contaminants," such as wet floors. The other falls on the same level occurred at "transition areas," such as from dry to wet, uneven surfaces, or one type of floor to another.

To fix the problems, you'll need details. "The accident investigations that we review [often] aren't specific enough to [find a] root cause," Schleckser says. "'Someone slipped on water because someone didn't clean it off.' How did the water get there? Dig deeper. You can't correct an issue by dealing with surface causes."

For example, you may find, as Schleckser did in one case, that water condensed on the outside of enclosed food carts and dripped on the floor.

Schleckser also recommends mapping slips and falls to look for a cluster of injuries. Analyzing hazards is an ongoing effort, he says. The task force should continue to meet on a biweekly or monthly basis, he says.

Keep up an awareness campaign

Fall-prevention strategies involve rethinking hospital design and changing employee behavior. No single piece of equipment will reduce injuries, as a mechanical lift or transfer device can in patient handling.

Instead, you may need to make many small changes: plastic bags at the entrances for wet umbrellas, longer entrance mats for wiping feet before they reach a slick floor, textured floor tiles in the food service area.

Collins compared the injury rates and workers' compensation costs for a 10-year period before, during, and after interventions were put into place. He found a 50% reduction in slip, trip, and fall workers' compensation claims in the post-intervention period.

The interventions varied in their impact. For example, the NIOSH study found that slip-resistant shoes could be very effective. In particular, slip-resistance tests conducted at the Finnish Institute found that one shoe made by Shoes for Crews outperformed others in laboratory tests with water, grease, and glycerol (a simulated oil), Collins says.

Rerouting downspouts and aggressive snow and ice removal in the winter helped prevent weather-related falls. BJC also focused on cord-bundling to remove tripping hazards. "We've had a broken leg just because a nurse got caught in a phone cord at the nurse station," notes Wolf.

Meanwhile, it's a challenge to keep up slip-and-fall awareness among employees. BJC incorporated slip-and-fall awareness in a health fair and used tabletop tents on cafeteria tables as reminders.

Employees could call a housekeeping hotline to report a spill and were encouraged to use pop-up tents that were placed throughout the hospital to cover spills until housekeeping arrived, Wolf says. The hospital also purchased special yellow absorption towels that employees could toss onto a spill until it was cleaned.

"It's a culture shift for the entire hospital," says Wolf. "It's a far-reaching goal. You have to work at it all the time."


1. Collins J, Bell JL, Gronqvist R, et al. Slip, trip, and fall (STF) prevention in health care workers. IEA Triennial Congress Proceedings, The Netherlands; 2006.

Recommendations from the NIOSH STF Study

The NIOSH slips-and-falls prevention study resulted in the following recommendations:

1. Hazard assessments should be conducted to identify environmental conditions or housekeeping procedures that could potentially contribute to an STF (Slip, Trip, and Fall) incident. The assessment should look for irregularities in the condition of walkway surfaces, objects and contaminants on the floor, cords, inadequate lighting, the appropriateness of handrail height and grip characteristics, and floor drains that may not be working properly.

2. Consider offering slip-resistant shoes to employees whose work exposes them to wet or greasy floors, such as housekeepers, nursing staff, food service workers, kitchen staff, dishwashers, and employees who decontaminate surgical instruments.

3. A sufficient number of mats with beveled edges should be placed at hospital entrances so that water is not tracked on the floor on rainy or snowy days. Mats with buckled or curled edges that could pose a tripping hazard should be replaced.

4. Effective procedures to degrease floors should be implemented in areas where food is prepared, cooked, and served.

5. Consider providing plastic disposable umbrella bags at hospital entrances. When wet umbrellas are placed in these bags, they collect water that would have otherwise been dripped on the floor.

6. When mopping, disinfecting, stripping or waxing floor surfaces, use highly visible, tall wet-floor signs in conjunction with barricades that block pedestrians from walking onto wet floors. Housekeeping staff should pick up wet floor signs promptly after the floor is no longer wet.

7. Develop a system that allows hospital employees to rapidly report spills to the housekeeping manager so spills can promptly be cleaned. Elevator areas and cafeteria exits are prone to drink spills. Cafeteria exits and elevator areas are good locations for wall-mounted paper towel holders.

8. Lids should be required for drinks.

9. Hazard assessments identified extensive cords under desks, nursing stations, and attached to medical equipment. Where feasible, use cord organizers, cord clamps, or retractable cord holders to minimize the hazard of tripping over cords.

10. In stairwells with potentially low visibility, consider painting the nosing on the top and bottom step to provide a visual cue to pedestrians.

11. Check parking areas, particularly covered garages, to ensure that lighting is adequate.

12. Check drains on a regular basis to ensure that there are no clogs or standing water.

Source: National Institute for Occupational Safety and Health, presented at the International Ergonomics Association Triennial Congress, The Netherlands; 2006.