Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): a Patient-Centered Fall Prevention Toolkit

Jt Comm J Qual Patient Saf. 2017 Aug;43(8):403-413. doi: 10.1016/j.jcjq.2017.05.002. Epub 2017 Jun 21.


Background: Patient falls during an acute hospitalization cause injury, reduced mobility, and increased costs. The laminated paper Fall TIPS Toolkit (Fall TIPS) provides clinical decision support at the bedside by linking each patient's fall risk assessment with evidence-based interventions. Strategies were needed to integrate this evidence into clinical practice.

Methods: The Institute for Healthcare Improvement's Framework for Spread is the conceptual model for pilot implementation of Fall TIPS at Brigham and Women's Hospital (BWH; Boston) and Montefiore Medical Center (MMC; Bronx, New York). The key to translating the evidence into practice was engaging stakeholders by leveraging existing shared governance structures, identifying unit champions, holding training sessions for all staff, and implementing auditing to assess and provide feedback on protocol adherence and patient outcomes.

Results: BWH unit compliance with using Fall TIPS averaged 82%, the mean fall rate decreased from 3.28 to 2.80 falls per 1,000 patient-days from January through June 2015 versus 2016, and the mean fall with injury rate for these periods decreased from 1.00 to 0.54 per 1,000 patient-days. At MMC, compliance averaged 91%, but the mean fall rate increased marginally from 3.04 to 3.10, while the mean fall with injury rate decreased from 0.47 to 0.31 per 1,000 patient-days. Patient knowledge survey results show improvement in knowledge of the risks for falls and the ways to prevent falls.

Conclusion: Engaging hospital and clinical leadership is critical in translating evidence-based care into clinical practice. Barriers to adoption of the protocol have been addressed and detailed to provide guidance for spread to other institutions.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Accidental Falls / prevention & control*
  • Clinical Protocols / standards*
  • Humans
  • Information Systems / organization & administration*
  • Information Systems / standards
  • Patient Safety / standards*
  • Pilot Projects
  • Quality Improvement / organization & administration
  • Risk Assessment
  • Wounds and Injuries / prevention & control*