Maryland Program Provides Road Map for Reducing Patient Falls

Heather Comak, for HealthLeaders Media , May 21, 2010

One of the more important aspects to consider when using the road map is that because it is a guide, it's perhaps not necessary for each facility to implement all of the suggested prevention techniques; instead, finding the best combination of strategies is the goal. It is a comprehensive guide, but not prescriptive, says Gary.

"Maybe it's not about implementing all of the audit questions or all of the strategies—maybe there's a perfect recipe, that if you implement x, y, and z, you're going to get the best results, so that's really what we're looking for in each of the settings," says Gary. The goal is to provide each facility the option of creating its own personalized falls program.

That sentiment was taken to heart at PRMC, and the facility has seen a decrease in both the number of falls and the number of patients who had falls with significant injury from 2007 through 2009.

"We decided that there might be things [on the road map] that we were not going to try to do," says McDonald. "I don't think this is an exercise where you answer 'yes' to everything—some things might not work for you." For instance, PRMC has elected to not have a pharmacy consult with a fall risk because of staffing and technology issues.

The goal of the SAFE from FALLS initiative in the coming months is to continue to recruit more hospitals and gather more data, says Gary. Additionally, the program will roll out a best practice monitoring tool statewide in July. The program will continue to develop an outpatient module for acute care facilities to use as well.

One of the largest benefits of participating in the collaborative for PRMC has been improving staff engagement levels, says McDonald. When someone from the MPSC visits the facility to check in on how the facility is working with the road map, staff plan events to display efforts on fall prevention. One instance involved a contest with each nursing department's falls educational boards exhibited in the hospital's lobby.

"That got people in the spirit, and that prompted many other similar types of [efforts] with other educational boards."

Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing

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