Risk Management Tools & Resources


Evaluating Your Hospital's Safety Culture as Part of Fall Prevention Initiatives

Laura M. Cascella, MA

Evaluating Your Hospital's Safety Culture as Part of Fall Prevention Initiatives

Falls are a common risk management and patient safety concern in U.S. hospitals. The Agency for Healthcare Research and Quality (AHRQ) estimates that each year, between 700,000 and 1 million people in the United States fall in hospitals.¹

Although some patient falls result in minimal or no harm, other falls can have severe consequences such as fractures, lacerations, or internal bleeding. For healthcare staff, falls can result in an increased workload (both in relation to patient care and documentation), poor satisfaction survey results, and litigation.

Various patient safety strategies and initiatives can help healthcare providers and staff work to reduce patient falls. However, successful implementation of these strategies can hinge on each organization's commitment to a culture of safety and transparency. AHRQ notes that "Achieving a culture of safety requires an understanding of the values, beliefs, and norms about what is important in an organization and what patient safety attitudes and behaviors are expected and appropriate."²

Consider the following characteristics of a solid safety culture, and identify areas in which your hospital is meeting or exceeding safety goals, as well as opportunities for improvement:

  • The organization has well-defined and documented safety protocols. These protocols are reviewed and updated periodically and when changes occur in workflows, systems, staffing, etc.
  • The organization's safety protocols clearly outline the types of incidents that require reporting and the appropriate reporting method.
  • The organization's leaders support safety initiatives, including fall prevention programs, through goal setting and resource allocation.
  • The organization has a code of ethics that promotes professionalism and encourages communicating with respect and courtesy.
  • The organization supports a nonpunitive approach to staff feedback and risk identification. Staff members do not fear retaliation when reporting safety issues.
  • Safety incidents are viewed as learning opportunities. When an incident occurs, the problem — not the individual(s) involved — is the focus of investigation and corrective actions.
  • A system is in place to evaluate corrective actions and their effectiveness, as well as to provide feedback to staff about the results of these actions.
  • The organization's leaders empower staff to make decisions and changes that support quality improvement.
  • The organization supports transparent communication with all healthcare providers and staff.
  • The organization measures performance and quality indicators and educates staff about data trends.
  • Hospital units work individually and collectively to improve care coordination and identify potential gaps in communication and information transfer.
  • The organization has a designated fall prevention team to evaluate fall risks, review incidents of falls, implement safety protocols, and monitor results.
  • The fall prevention team includes appropriate representatives from across the organization, such as physicians, nurses, nursing assistants, physical therapists, occupational therapists, risk managers, facility engineers, and environmental services staff.

For more information about evaluating and improving your hospital's fall prevention program, see AHRQ's comprehensive resource titled Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.


¹ Agency for Healthcare Research & Quality. (2013, January). Preventing falls in hospitals: A toolkit for improving quality of care. Retrieved from www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html

² Agency for Healthcare Research & Quality. (2013, January). Preventing falls in hospitals: A toolkit for improving quality of care. Tool 1A: Hospital survey on patient safety culture. Retrieved from www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool1a.html

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