Reducing Harm from Falls with Teamwork and Focused Assessment

Reducing Harm from Falls with Teamwork and Focused Assessment
Sentara Virginia Beach General Hospital
Virginia Beach, Virginia, USA

Sentara Virginia Beach General Hospital (SVBGH) was a participant in Reducing Patient Injuries from Falls, part of the RWJF/IHI Transforming Care at the Bedside (TCAB) initiative.
Suzanne Rita, MSN, RN, Project Leader
Ginni Scharfe, BS, RN, SVBGH Fall Prevention Leader
Irene Selbrede, RN, SVBGH 4E Pilot Unit Leader

Our aim was to reduce patient injury from falls at all Sentara Healthcare Systems hospitals to a rate of no more than one fall associated with moderate-to-severe injury per 10,000 patient days. This report focuses on improvements on the Sentara Virginia Beach General Hospital pilot unit [4E, which cares for medical, surgical, and oncology patients] during the time frame of July 2006 through June 2007.

  • Falls associated with moderate-to-severe harm per 1,000 adjusted patient days*
  • Falls rate per 1,000 patient days
*The team converted data to “harm per 10,000 adjusted patient days” by multiplying the data by 100.


Our team recognized patients at risk for injury from a fall might be missed when a standard fall assessment was used. To prevent this, we developed a tool to identify patients at risk for harm from a fall: The ABCs High Risk To Harm (HRTH) assessment tool. This was created in collaboration with other hospital teams participating in the IHI Reducing Patient Injuries from Falls initiative.

The pilot unit at Sentara Virginia Beach General Hospital tested the tool and discovered that some patients at risk for harm from falls were not necessarily at greater risk for falling. The team then combined their falls risk assessment with the HRTH tool to assess patients for both falls and risk of injury from a fall. [NOTE: The assessment tool and other tools can be found in Section Four of the TCAB How-to Guide: Reducing Patient Injuries from Falls.]
Other tested changes included:
  • Safety Huddles: At the beginning of each shift, front-line staff gather together and identify patients at highest risk for injury, including fall-related injury, using a form developed by the team to list at-risk patients.
  • Fall Follow-Up: A unit-based fall prevention expert immediately reviews with front-line staff the circumstances regarding every fall and documents the information on this form.
  • Safe Exit: Using the PDSA cycle, the team developed a “Safe Exit” strategy for transferring patients out of a bed:
    • The team simulates the patient’s room at home, based on patient and family information (e.g., bed position relative to bathroom), and identifies a “safe” exit to the bathroom.
    • The team posts visual aides in the patient’s room to cue him or her to the safe side of the bed from which to exit.
  • The team took several steps to increase the reliability of these processes, including:
    • Consistently communicating about fall-related injury by adding “risk for injury” to the shift handoff report tool;
    • Using post-fall huddles to identify factors that led to falls and ideas for mitigating them; and
    • Sharing the analysis of fall-related data with all system hospitals to mitigate falls and injury from falls.
The graphs below show hospital-wide data that reflects the spread of the successful ideas that were initiated on the SVBGH pilot unit:
  • January 2007: Tested of ABCs HRTH fall injury tool and addition of “high risk to harm” to standardized shift report tool
  • February 2007: Safety huddles tested and refined
  • March 2007: Fall follow-up process tested and refined; fall expert follow-up tested and refined
  • June 2007: Tested safe exit on different pilot unit







Summary of Results / Lessons Learned / Next Steps

The Sentara Healthcare System leaders reinforced their dedication to fostering a culture of safety through their commitment to initiatives to prevent fall-related injury. The steps taken to prevent falls provided a framework for improvements and promoted an environment that encourages critical thinking, one in which all members of the hospital team “have a questioning attitude.” Having a Questioning Attitude is just one of our five behavior-based expectations (BBE). Our other BBEs include: Pay Attention to Detail, Communicate Clearly, Effective Handoffs, and Never Leave Your Wingman. Our culture of safety provided the necessary foundation for improving our fall and fall with injury rates.

Contact Information
Stephanie S. Jackson, RN, MSN, ACNS-BC
Manager, Patient Care Services, Education Department, Diabetes and ET Services
Sentara Norfolk General Hospital


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