NRS490 Literature Review.docx - 1 Running head FALL...

1
Running head: FALL PREVENTION AND A CULTURE OF SAFETY
Fall Prevention and a Culture of Safety: Literature Review
Grand Canyon University: NRS-490-O504
February 23, 2020

2
FALL PREVENTION AND A CULTURE OF SAFETY
Fall Prevention and a Culture of Safety: Literature Review
Patient safety is one of the biggest priorities for healthcare workers and falls are one of
the most common patient safety issues in healthcare organizations (Coppedge et al, 2016).
Patient falls are listed as a “never event” by the Centers for Medicare and Medicaid Services
(CMS). Never events are defined as high cost, high volume events that could be prevented
through the implementation of evidence-based protocols (King et al., 2018). Falls are a leading
cause of injury in patients over the age of 65 and are the number one cause of unintentional death
in patients 85 and older (Quigley, 2015). Patient falls are a multifactorial issue and not one fall
prevention measure can prevent all falls. Falls can be due to physiological reasons where a fall
risk can be anticipated such as unsteady gait, physiological reasons that may be unforeseen such
as fainting and environmental factors such as tripping over equipment (King et al., 2018). With
any fall comes the risk for injury or even death. Injuries sustained by an inpatient can lead to
longer hospital stays and increased health care costs for the patient and the hospital (Leone &
Adams, 2015). When establishing fall prevention protocols, it is important that all factors are
taken into consideration (King et al., 2018). Many studies have been performed on fall
prevention protocols and safety culture and their effects on fall rates in many different inpatient
facilities with differing results. This paper will compare the research questions, sample
populations, and study limitations of eight different studies that deal with fall prevention protocol
implementation and safety culture development.
Research Questions
The main focus of most of the studies compared in this paper is to identify fall prevention
interventions that can be used to decrease fall rates on inpatient units. Coppedge et al. (2016)

3
FALL PREVENTION AND A CULTURE OF SAFETY
researched the question on whether a standardized fall prevention communication tool could
decrease fall rates. This tool improved multidisciplinary communication amongst the medical