Simple strategies can help reduce falls and liability in your facility

Women and elderly fall more frequently

Slips, trips, and falls happen in any health care setting, and they can be enormously expensive. The good news is that you can sharply reduce those accidents by aggressively employing some rather simple strategies. It’s simple, but not necessarily obvious. Sure, your housekeeping staff clean up spills when they’re reported, but how fast? Have you ever had someone slip in a spill between the time it was reported and the time it was actually cleaned up? It happens.

Thinking about realities like that is a big step toward reducing slips and falls, says Ruth M. Maher, PT, DPT, MPT, BS, director of physical therapy at HyOx Medical Treatment Center in Marietta, GA. HyOx is a comprehensive outpatient rehabilitation facility and Maher has worked in reducing slips, trips, and falls in a variety of health care settings. "The cost and effort required to reduce these incidents is far less than what is required to deal with the aftermath, especially if it results in legal action," she says.

Falls likely to result in injuries

Maher notes that among U.S. industries with 100,000 or more injuries and illnesses, hospitals have the second highest rate of nonfatal injury or illness cases.1 When one considers that injuries from falls are approximately 40% greater in hospitals than in general industry, it is not surprising that the National Institute for Occupational Safety and Health (NIOSH) in Washington, DC, along with the Finnish Institute of Occupational Health, Johns Hopkins School of Public Health in Baltimore, and Liberty Mutual Research Institute in Hopkinton, MA, are conducting a study of transient risk factors which may lead to occupational slips and falls in hospital settings.

Pilot data from last year showed that among those who slipped or fell, 86% were women, 36% were nurses, and 12% were employed in housekeeping. The hospital workers were asked a series of questions about the circumstances prior to the incident. Fifty-five percent fell after slipping and 41% after tripping. Thirty-four percent of incidents involved liquid such as water or cleaning solutions, and 59% occurred at a transitional area (such as wet to dry, from one type of floor to another, or uneven surfaces).

Ninety-one percent of workers were injured as a result of the incident with typical injuries including contusions (23%), strains and sprains (22%), and fractures (9%). The pilot study also showed that the injured workers’ exposure to causative factors such as contaminated floors, unfamiliar pathways, rushing, carrying atypical loads, and distraction was greater at the time of the injury than it had been in the previous month.

Women most at risk

Maher says it is important to note that the median age of workers who slipped, tripped, and/or fell was 46 years, and most were women. This should raise significant concerns as the prevalence of osteoporosis increases with age. This essentially predisposes older women who slip, trip, or fall to more serious injuries than those who are younger.

In 2001, more health care workers were injured than workers in any other sector, and slips, trips, and falls accounted for the largest proportion of lost-time injuries (21%), according to information from the U.S. Bureau of Labor Statistics.

Advocate South Suburban Hospital in Hazel Crest, IL, was no exception to those statistics. After a series of falls that got the administration’s attention, Mary Lange, RN, BSN, MHA, CPHQ, CRM, director of quality risk management, implemented several initiatives to prevent patient and employee falls at the hospital. She also is part of a larger task force for an eight-hospital system that is focusing on this specific issue.

A root-cause analysis revealed one clue right away: Reducing slips and falls may involve departments you had never considered. At Advocate, the team conducting the root-cause analysis included the department responsible for ordering equipment because Lange realized the specific products in use can affect the risk of slips and falls. "We discovered that the system was considering ordering new restraints, so we thought that was a great time to look at which particular items can contribute to falls or lessen them," she says.

Halcion can be special risk

The team also analyzed the hospital’s own fall data and found that, consistent with the national data, most patients who fell were elderly women. Next, the team looked at ways to reduce falls and pinpointed some particular strategies. "We noted that there was research showing Halcion [triazolam] contributed to some falls, particularly at night. It has to do with the fact that as you age, your kidneys don’t function as well and can’t throw off the medicine as quickly, so you end up overdosing in a way," she says. "So we did education through our pharmacy newsletter to physicians about appropriate dosing of Halcion."

Advocate also educated nurses about how patients might not be at risk of falling when they first come to the hospital, but they might be at risk later after receiving medications and after other changes. The hospital also has experimented with different automated systems that can help keep elderly and confused patients in bed without being restrained. The systems can be triggered by movement and use the recorded voice of spouses or other family remembers to remind the patient to stay in bed.

Post-fall protocol necessary

The Advocate team also determined that the system lacked a post-fall protocol, leaving it up to nurses to determine how to respond after a fall. So Advocate immediately implemented a post-fall protocol that requires staff to take certain actions. Among other standard steps like recording the conditions causing the fall, the Advocate plan calls for computed tomography scans of some high-risk patients, like those on blood thinning drugs, to rule out subarachnoid hemorrhage and other hidden injuries. The protocol ensures that post-fall procedures are the same from one unit to the next, Lange says.

The new plan has been in place at Advocate for fewer than six months, and each unit reported a reduction in falls of from 2% to 4% over the first quarter. Advocate has not yet determined the cost savings that may accrue from that reduction, but Lange says she expects the savings to be substantial and to make up for any expenses incurred in the fall reduction program.

Most hazards can be addressed

Risk managers must have an occupational health and safety plan, and an appropriate safety culture and working environment in order to address the incidence of falls, Maher urges. Safety culture seeks to develop an awareness, to value the importance of making safety an integral part of your company’s culture and to develop an awareness of the importance of accountability in an effective safety program. "Fall prevention is everyone’s business," she says. "I’d like to see everyone in the organization participate in a fall prevention program at least once a year. Show them how much these accidents cost and that there are very concrete ways to reduce them, strategies that actually show results."

A successful prevention program can address most, if not all, of the controllable factors, she says. For example, there must be a formal written program dealing with floor treatments. The floor treatment that is most appropriate for a particular work environment will depend on the nature of the floor and the hazards that are present. The plan should address appropriate cleaning protocols for each contaminant, the use of signage/ warnings, and the training of employees in proper cleaning techniques procedures.

"Just mopping a spill is not enough. That often can just spread the contaminant," she says. "A thorough cleaning may require abrasives or other techniques. This isn’t always as simple as just wiping up the spill and moving on."

Lange says it is key to measure your results with fall prevent programs. Once you see how your falls data are affected by particular strategies, you can keep the things that work and ditch the things that don’t. She also urges risk managers to consult physical therapists like Maher. "They understand better than most people what some patients are coping with, issues like how high a bed should be set or what kind of beds to order," she says. "A physical therapist can tell you that with patients so much more acutely ill, it’s hard to get patients back in bed. Those cushy, soft mattresses may look good, but patients can slide right off of them."

Even the most common equipment used by staff can increase or reduce the risk of falls, she says. Did you know that office chairs come with two different types of wheels — one intended for carpet and one type for hard surfaces? "If you borrow a chair from down the hall and it’s the wrong type, it can slip right out from under you," she says. "That’s the kind of thing we’d never considered until we took a very comprehensive look at what causes falls."

Fast track for cleanup

Frequent inspections of high-traffic areas and keeping a written log of each inspection can be a critical element in defending against a lawsuit, a real danger should a nonemployee slip in your facility, Maher notes. She also recommends that you do some risk management by walking around. Reading incident reports in your office is one thing, Maher says, but you might gain much better insight by touring the facilities once in a while with an eye toward slip and fall hazards. "You also need a fast track for getting things fixed," she says. "When someone reports that there is a fall hazard, you need a way to get that fixed right away rather than waiting for the paperwork to go through. That also encourages people to report these hazards when they see that you will address them immediately."

Maher also recommends using a free tool offered by OSHA. The Hospital E Tool provides a computerized way to help employers identify and address potential occupational hazards in hospitals. The tool can help employers in developing and implementing engineering and work practice controls that comply with OSHA requirements, and Maher suggests they could be incorporated into a facility’s safety and health plan to reduce the hazards of hospital work and improve worker safety. The Hospital E tool is available at


1. Courtney T, Wellman H, Lombardi D, et al. Slips, trips, and falls in hospital workers — Pilot outcomes. Presented at the American Industrial Hygiene Conference and Expo by the American Industrial Hygiene Association. Atlanta; May 8-13, 2004.