Joe P Tomsic
BSN, MHPA, MN
RN, ARNP, NEA-BC, PMHNP-BC
© Copyright by Joseph Patrick Tomsic, 2012
All Rights Reserved
This document should guide healthcare professionals reviewing
their current falls and fall injury prevention program. In n...
 20-years of nursing leadership experience
◦ Board certified nurse executive-advanced and Psychiatric
Mental Health Nurse...
 Introduction
 Scope of the Issue
 Why Do Patients Fall?
 Sequelae from Falls
 Psychiatric Nurse Practitioner Role
 ...
 Falls rate in hospitals is between 2.2-
17.1 per 1000 patient days
 The healthcare facility rate is three
times higher ...
 Second only to the medication events
 The leading cause of nonfatal injuries
 Leads to negative outcomes
 Prolongs ho...
 Individual (intrinsic) factors
◦ Comorbidities
◦ Behavioral disturbance
◦ Agitation
◦ Confusion
◦ Vision problems
◦ Deli...
 Environmental (extrinsic) factors
◦ Poor workflow design
◦ Inadequate lighting
◦ Trip hazards
◦ Faulty equipment
◦ Poorl...
 Five high risk areas
1) Medications
Antipsychotics
Benzodiazepines
Sedative/hypnotics
Digoxin medications
2) Orthostatic...
Past history of a fall is the
single best predictor of
future falls
30% to 40% of patients
who fall will do so again…
 High risk nursing units
◦ Psychiatric
◦ Oncology
◦ Orthopedic
◦ Neurology
◦ Geriatric units
 Classifications of patient...
 Injuries occur in 15% to 50% of falls
Range: Bruises-minor injuries-severe soft
tissue wounds-Skeletal fractures-Death
...
 Approximately 1 in 10 falls will result
in a serious injury
 After adjusting for age
◦ Fall fatality rate in can be up ...
 The psychiatric liaison consultant has
a growing role in acute care hospitals
 The psychiatric nurse practitioner
(PNP)...
 When almost all the patients are HRF,
the focus needs to shift from
identification to intervention
 Two goals for a suc...
 Effective interventions are part of a
basic universal fall program
◦ Assessment of all patients for risk of falling
◦ A ...
 Hospitals successful at reducing fall
rates
◦ Developed a culture of safety
◦ Used fall-risk assessments
◦ Deployed mult...
 The causes of falls are multifactorial
◦ Intrinsic risk factors
◦ Extrinsic risk factors linked to the environment
 Wor...
 Withdrawal or reduction of
psychotropic medications
 Delirium avoidance program
 Reducing sedative and hypnotic
medica...
 SBAR is a form of structured
communication adapted from aviation
and the military
 SBAR acronym
◦ Situation (S; what is...
SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.
Follow your institution’s patient fall ...
SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only.
Follow your institution’s patient fall ...
 A fall-risk assessment is required to
meet the Joint Commission standards
 Commonly used fall-risk assessments
◦ Morse ...
Risk Factors Edmonson
The Johns Hopkins
Fall Risk Assessment
Tool
The Conley Scale Morse Falls Scale Tinetti
Hendrich II F...
 Psychiatric professionals can
accomplish a fall risk assessment with
every intake simply by increasing their
awareness o...
 The most common cause of accidental
death amount older adults
 5th leading cause of older adult death
◦ Seniors older t...
 Patients do not generally regain pre-
injury levels of physical functioning
 Seniors with mild Alzheimer's may not
adap...
 Develop a delirium avoidance program
as a key intervention
 Use a risk screening tool but consider
also rank ordering p...
 Involve the psychiatric liaison team
◦ Add fall risk screening to psychiatric
intakes
◦ Add fear of falling to the multi...
 Develop chart audit processes
 Develop realistic training including
role playing and hands-on training
 Track the cost...
 Apply Lean principles to any fall
prevention program
 Incorporate fall prevention
interventions into the nurse’s
workfl...
 Place patients in the High Risk for
Falls (HRF) subgroup on bed alarms or
document the reason why a bed alarm
is not app...
 Place patients at the “highest” HRF
next to nursing station
 Also consider non-HRF patient rooms
e.g. rooms too far fro...
 Track close calls e.g. HRF patient self
ambulates to bathroom
 Develop visual tools
◦ Strategically located
 List “Pri...
 Develop process to make “Fall Safe
Patient Assignments”
◦ Ensure that nursing assignments are
acuity neutral so nurses h...
 Develop fall risk hand-off
communication process
◦ Awareness of patients with bed alarms
◦ Nurses share falls risk for t...
1. An, F., Xiang, Y., Lu, J., Lai, K., & Ungvari, G. (2009). Falls in a Psychiatric Institution in Beijing, China. Perspec...
8. Compton, J., Copeland, K., Flanders, S., Cassity, C., Xiao, Y., & Kennerly, D. (2012). Implementing SBAR Across a Large...
17. Lovallo, C., Rolandi, S., Rossetti, A. M., & Lasignani, M. (2009). Accidental falls in hospital inpatients: evaluation...
24. Ryan, J. J., McCloy, C., Rundquist, P., Srinivansan, V., & Laird, R. (2011). Fall Risk Assessment Among Older Adults W...
Preventing Patient Falls in Acute Care Hospitals
Preventing Patient Falls in Acute Care Hospitals
Preventing Patient Falls in Acute Care Hospitals
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Preventing Patient Falls in Acute Care Hospitals

Published on: Mar 4, 2016
Source: www.slideshare.net


Transcripts - Preventing Patient Falls in Acute Care Hospitals

  • 1. Joe P Tomsic BSN, MHPA, MN RN, ARNP, NEA-BC, PMHNP-BC © Copyright by Joseph Patrick Tomsic, 2012 All Rights Reserved
  • 2. This document should guide healthcare professionals reviewing their current falls and fall injury prevention program. In no way does this document contain all possible options for developing a falls and fall injury prevention program. Do not use this document as the sole source for developing a falls and fall injury prevention program. Instead, view it as additional information for the development of a fall injury prevention program that matches the complexity of your organization. This presentation is available for use only with permission from the author. The conclusions in this outline are based on available research and represent the opinion of the author. The “Fall Prevention Intervention Workflow Wheel®” , “Fall Prevention Pillars®” and “SBAR Fall Prevention Tool®” are available for use with permission of the author only.
  • 3.  20-years of nursing leadership experience ◦ Board certified nurse executive-advanced and Psychiatric Mental Health Nurse Practitioner  United States Air Force, Major, Nurse Corps ◦ Psychiatric Nurse Practitioner  Education ◦ Master of Nursing, Psychiatric Nurse Practitioner  University of Washington ◦ Master of Health Policy and Administration  Washington State University ◦ Bachelor of Science in Nursing  Seattle Pacific University
  • 4.  Introduction  Scope of the Issue  Why Do Patients Fall?  Sequelae from Falls  Psychiatric Nurse Practitioner Role  Interventions  Fall Prevention Interventions Workflow Wheel  Medication Interventions  SBAR  Risk Identification Scales  Example documentation of fall risk  Geriatric Considerations  Recommendations
  • 5.  Falls rate in hospitals is between 2.2- 17.1 per 1000 patient days  The healthcare facility rate is three times higher than the community  Approximately 15,000 people 65 and older die from falls each year  Patient falls result in costs of more than $20 billion a year
  • 6.  Second only to the medication events  The leading cause of nonfatal injuries  Leads to negative outcomes  Prolongs hospitalization  Legal liability  Still searching for an answer….
  • 7.  Individual (intrinsic) factors ◦ Comorbidities ◦ Behavioral disturbance ◦ Agitation ◦ Confusion ◦ Vision problems ◦ Delirium ◦ Muscle weakness ◦ Urinary incontinence ◦ Impaired balance
  • 8.  Environmental (extrinsic) factors ◦ Poor workflow design ◦ Inadequate lighting ◦ Trip hazards ◦ Faulty equipment ◦ Poorly defined processes ◦ Nursing unit design flaws ◦ Staff attitude ◦ Lack of education
  • 9.  Five high risk areas 1) Medications Antipsychotics Benzodiazepines Sedative/hypnotics Digoxin medications 2) Orthostatic hypotension 3) Poor vision 4) Impaired mobility 5) Unsafe behavior
  • 10. Past history of a fall is the single best predictor of future falls 30% to 40% of patients who fall will do so again…
  • 11.  High risk nursing units ◦ Psychiatric ◦ Oncology ◦ Orthopedic ◦ Neurology ◦ Geriatric units  Classifications of patient falls ◦ Accidental ◦ Anticipated physiological ◦ Unanticipated physiological
  • 12.  Injuries occur in 15% to 50% of falls Range: Bruises-minor injuries-severe soft tissue wounds-Skeletal fractures-Death  Patient falls account for about 65,000 hip fractures annually  Falls contribute to a 50% higher mortality  Loss of confidence, anxiety and depression, and PTSD
  • 13.  Approximately 1 in 10 falls will result in a serious injury  After adjusting for age ◦ Fall fatality rate in can be up to 49% higher for men ◦ Women are 67% more likely than men to have a nonfatal fall injury
  • 14.  The psychiatric liaison consultant has a growing role in acute care hospitals  The psychiatric nurse practitioner (PNP) is uniquely trained to lead patient fall prevention initiatives.  PNPs are trained to work with patients who are confused, agitated, delirious, demented, non-compliant, and on sedating medications
  • 15.  When almost all the patients are HRF, the focus needs to shift from identification to intervention  Two goals for a successful strategy ◦ Promotion of nurses’ professional knowledge and skills in implementing a fall prevention program ◦ Cultivation of nurses’ attitudes in treating patients as their own families
  • 16.  Effective interventions are part of a basic universal fall program ◦ Assessment of all patients for risk of falling ◦ A culture of safety ◦ Hospital protocol for those at risk of falling ◦ Enhanced communication of risk of injury from a fall ◦ Customized interventions for those at risk of injury from a fall
  • 17.  Hospitals successful at reducing fall rates ◦ Developed a culture of safety ◦ Used fall-risk assessments ◦ Deployed multifactorial interventions ◦ Conducted post fall follow-up ◦ Involved quality improvement ◦ Integrated risk screening within the electronic medical record
  • 18.  The causes of falls are multifactorial ◦ Intrinsic risk factors ◦ Extrinsic risk factors linked to the environment  Workflow redesign is more pressing than ever ◦ Introduction of new technologies ◦ New treatment methodologies
  • 19.  Withdrawal or reduction of psychotropic medications  Delirium avoidance program  Reducing sedative and hypnotic medications  Supplementation with vitamin D and/or of calcium
  • 20.  SBAR is a form of structured communication adapted from aviation and the military  SBAR acronym ◦ Situation (S; what is the situation?) ◦ Background (B; what is the background information?) ◦ Assessment (A; what is your assessment of the situation?) ◦ Recommendations (R; how do you recommend the problem be resolved?)
  • 21. SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only. Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents SBAR Hand-off Introduce yourself to the oncoming shift by name, title, and nursing unit. Prior to change of shift complete an assessment of fall risk. Provide the oncoming care provider with the patient’s risk factors. If using bedside reporting include the patient and family in fall risk education. Situation: [patient] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently [oriented X_], [confused], [lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain]. Patient with [multiple comorbidities], [behavioral disturbance], [agitation or confusion], [vision problems], [delirium], [muscle weakness], [urinary incontinence], [impaired balance]. Physically check bed alarm is on and functioning with ongoing shift. Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded], [confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number]. Assessment: Patient is not responding to redirection or [state interventions] and has made ___ exits attempts in the past ___ hours. The patient is at risk due to use of [antipsychotics], [benzodiazepines], [sedative/hypnotics], [digoxin] [orthostatic hypotension], [poor vision], [impaired mobility], [unsafe behavior]. Patient with behavioral disturbance as evidenced by [agitation], [confusion]. Patient with vision problems and glasses are [on],[at bedside], [remind family to bring in]. Patient currently be treated for [delirium], [ETOH/Opiate withdrawal]. Ambulation impaired due to [muscle weakness], [impaired balance ]. Provide frequent toileting due to [urinary incontinence], [diarrhea]. Recommendations: Additional orders [Medication change], [1:1 observation], [restraints], [enclosure bed] or [other]. Nursing interventions [move closer to nursing station], [bed exit alarm], or [other]
  • 22. SBAR Fall Prevention Tool was developed J.P. Tomsic. For use with permission only. Follow your institution’s patient fall policy e.g. notifying the falls provider and reporting patient incidents SBAR After a Fall Introduce yourself to the provider by name, title, and nursing unit. Provide lifesaving care if the patient is in acute distress or rapidly deteriorating call a code and get help! Complete an assessment (do not move if injured) and provide the provider with the patient’s condition. Situation: [patient] fell on [date] at [time]. [he/ she] is [age] admitted on [date] with a current diagnosis of [diagnosis]. The patient’s is currently [oriented X_], [confused], [lethargic], [Dizzy], [lightheaded], [unconscious], [seizing], or [other]. The patient is complaining of [_ out of 10 pain], or appears to be in pain as evidenced by [overt signs of pain such as grimacing, moaning, guarding]. Additional items to report: The patient currently has [chest pain], [difficulty breathing], [numbness], [suspect a c-spine injury] or [other]. Current vital signs (including pulse oximetry) are [state]. Background: [patient name], [level of activity]. The patient [does] or [does not] have a history of falls. The patient [does] or [does not] have a history of seizures. The patient [does] or [does not] have a history of orthostatic hypotension. The patient [does] or [does not] has a history of behavior such as [throwing himself onto the floor] or [other]. The [patient] [does] or [does not] have a history of [dizziness], [lightheaded], [confused], [agitation], [seizures] or [anything else] that may contributed to the fall risk. The patient’s last Fall Risk Scale score was [number]. Assessment: Condition is at [baseline] or [has changed]. The patient [does] or [does not] appear to have an injury. The patient appears to have sustained a [head injury] as indicated by [overt signs such as cuts, abrasion, bump, or swelling on the head], [visual changes] or [headache] from the fall. The patient appears to have sustained a [possible fracture] AEB [location of deformity or swelling] or difficulty moving, [LLE, RLE, LUE, RLE etc.] from the fall. The patient appears to have sustained a [neck injury] AEB [numbness] to [extremity]. The patient has a [bruise], [scratch], [hematoma], [laceration] [superficial wound] on [location]. The injury appears to be [mild], [moderate], [severe]. Recommendations: recommend [provider assessment], [pain medication], [X-ray], [transfer, emergency room] or [other]. The patient is requesting [pain medication], [anxiety medication], or [other].
  • 23.  A fall-risk assessment is required to meet the Joint Commission standards  Commonly used fall-risk assessments ◦ Morse Fall Scale (MultiCare Health System) ◦ Hendrich Falls Risk Model II ◦ Edmonson Psychiatric Fall Risk Assessment Tool (Memorial Hospital in Illinois) ◦ The Conley Scale ◦ Tinetti Balance Assessment Tool (Western State Hospital) ◦ The Johns Hopkins Fall Risk Assessment Tool (UW Medical Center)
  • 24. Risk Factors Edmonson The Johns Hopkins Fall Risk Assessment Tool The Conley Scale Morse Falls Scale Tinetti Hendrich II Fall Risk Model Psychiatric Assessment Risk Assessment Questions? No Yes (Low Risk if complete paralysis immobilized, High risk if history of > one fall within 6 months or fall during hospitization) No Yes (IV or IV Access is 25 points) No No Past Medical History Age? Yes Yes No No No No Identifying Information Mental Status or Cognition? Yes Yes (cognition) Yes (Orientation, Agitation, Impaired Judgement) Yes (oriented abulation ability and limitations) No Yes (confusion, disorientation, impulsivity, depression) Mental Status Examination Altered Elimination? Yes Yes Yes (Bathroom in a hurry, wet or soil self on way to bathroom, up at night to use BR) No No Yes Past Medical History Medications? Yes Yes No No No Yes (antiepileptics, Benzodiazepines) Past Medical and Psychiatric History Diagnosis? Yes No No Yes No No Multiaxial Diagnosis Ambulation and Balance? Yes Yes (mobility) Yes (difficulty getting out of bed or chair, Using supports, weak) Yes (Gait) Yes (various maneuvers that takes 8-10 minutes to complete and requires training) Yes (get and go test) Mental Status Examination Screening for abnormal movement and gait Nutrition? Yes No No No No No Screening for depression Sleep Disturbance? Yes No No No No No Screening for various psychiatric diagnosis depression and bipolar History of Falls? Yes Yes Yes (last 3-months) Yes No No Past Medical History
  • 25.  Psychiatric professionals can accomplish a fall risk assessment with every intake simply by increasing their awareness of the items included in a falls risk assessment  Example questions ◦ “Have you had any falls in the past 6-months or during the hospitalization?” ◦ “Are you having any issues going to the bathroom such as urgency or getting up at night?”
  • 26.  The most common cause of accidental death amount older adults  5th leading cause of older adult death ◦ Seniors older than 80 years are most likely to be injured  Older adults with mental illness are at increased risk for both falls and subsequent fractures
  • 27.  Patients do not generally regain pre- injury levels of physical functioning  Seniors with mild Alzheimer's may not adapt mobility behavior to match cognitive and physical impairments  Frontal lobe dysfunction ◦ Disinhibition of behavior ◦ Poor judgment ◦ Movement disorders
  • 28.  Develop a delirium avoidance program as a key intervention  Use a risk screening tool but consider also rank ordering patients by fall risk ◦ Consider a parallel process to rank order patients by degree of falls risk in addition to the hospital-wide falls risk assessment scale
  • 29.  Involve the psychiatric liaison team ◦ Add fall risk screening to psychiatric intakes ◦ Add fear of falling to the multiaxial assessment ◦ Review medications for all HRF patients ◦ Develop a process to review all patient falls within 24-hours
  • 30.  Develop chart audit processes  Develop realistic training including role playing and hands-on training  Track the cost of falls and use this information to calculate the return on investment for new equipment, staff education or items such as electronic incident reporting
  • 31.  Apply Lean principles to any fall prevention program  Incorporate fall prevention interventions into the nurse’s workflow  Implement bedside change of shift handoff communication ◦ Use standardized communication
  • 32.  Place patients in the High Risk for Falls (HRF) subgroup on bed alarms or document the reason why a bed alarm is not appropriate ◦ Develop a standard algorithm for bed-exit monitoring ◦ Monitor time from bed-exit alarm to staff response  Add bed-exit attempts to the RN to RN and charge nurse report
  • 33.  Place patients at the “highest” HRF next to nursing station  Also consider non-HRF patient rooms e.g. rooms too far from nursing station to quickly respond  Review patient fall data to determine each unit’s “Fall Safe Zones” ◦ Chart audit results often substantiate safer rooms ◦ Conduct a “Safety Reshuffle” q shift
  • 34.  Track close calls e.g. HRF patient self ambulates to bathroom  Develop visual tools ◦ Strategically located  List “Priority High Risk to Fall“ patients  Risk for current shift  Patient on alarms  Alarm standards  Patients with communication issues  More
  • 35.  Develop process to make “Fall Safe Patient Assignments” ◦ Ensure that nursing assignments are acuity neutral so nurses have time to frequently check patients. ◦ Develop process for nursing staff input on falls risk acuity, falls risk and bed alarm data to build an overall risk profile for patients each shift
  • 36.  Develop fall risk hand-off communication process ◦ Awareness of patients with bed alarms ◦ Nurses share falls risk for the oncoming shift ◦ Standardized interventions for patients at the highest risk for falling  Have the charge nurse read the names of each “Priority High Risk to Fall”, High Risk to Falls with bed alarm as part of a 2-minute overview
  • 37. 1. An, F., Xiang, Y., Lu, J., Lai, K., & Ungvari, G. (2009). Falls in a Psychiatric Institution in Beijing, China. Perspectives in Psychiatric Care, 45, 183-190. 2. Annweiler, C., Montero-Odasso, M., Schott, A. M., Berrut, G., Fantino, B., & Beauchet, O. (2010). Fall prevention and vitamin D in the elderly: an overview of the key role of the non-bone effects. Journal of Neuroengineering and Rehabilitation, 1-13. 3. Behavioral Health Edmonson Psychiatric Fall Risk Assessment Tool. (2012). Retrieved from https://www.memorialmedical.com/Services/Behavioral-Health/Edmonson-Psychiatric-Fall-Risk-Assessment.aspx 4. Bronheim, H. E., Fulop, G., Kunkel, E. J., Muskin, P. R., Schindler, B. A., Yates, W. R.,...Stoudemire, A. (1998). The Academy of Psychosomatic Medicine Practice Guidelines for Psychiatric Consultation in the General Medical Setting. Psychosomatics, 39, 8-30. 5. Cain, C., & Haque, S. (2008). Chapter 31. Organizational Workflow and Its Impact on Work Quality. In Patient Safety and Quality An Evidence-Based Handbook for Nurses (Section IV: Working Conditions and the Work Environment for Nurses). Retrieved from http://www.ahrq.gov/qual/nurseshdbk/ 6. Chatterjee, S., Chen, H., Johnson, M. L., & Aparasu, R. R. (2011). Risk of Falls and Fractures in Older Adults Using Atypical Antipsychotic Agents: A Propensity Score–Adjusted, Retrospective Cohort Study. The American Journal of Geriatric Pharmacotherapy, 1-12. 7. Chung, M. C., McKee, K. J., Austin, C., Barkby, H., Brown, H., Cash, S.,...Pais, T. (2009). Posttraumatic Stress Disorder in older people after a fall. International Journal of Geriatric Psychiatry, 24, 955-964.
  • 38. 8. Compton, J., Copeland, K., Flanders, S., Cassity, C., Xiao, Y., & Kennerly, D. (2012). Implementing SBAR Across a Large Multihospital Health System. The Joint Commission Journal on Quality and Patient Safety, 38, 262-268. 9. Conley, D., Schultz, A. A., & Selvin, R. (1999). The Challenge of Predicting Patient at Risk of Falling: Development of the Conley Scale. MedSurg Nursing, 8, 348-354. 10. Doherty, M., & Crossen-Sills, J. (2009). Fall Risk Keep Your Patient in Balance. The Nurse Practitioner, 34, 46-51. 11. Falen, T., Unrub, L., & Segal, D. (2011). Electronic Fall Surveillance System Model. The Health Care Manager, 30, 342-351. 12. Galbraith, J. G., Memon, A. R., & Harty, J. A. (2011). Cost Analysis of a Falls-prevention Program in an Orthopaedic Setting. Clinical Orthopaedics and Related Research, 12, 3462-3468. 13. Hendrich, A. (2007). Predicting Patient Falls Using the Hendrich II Fall Risk Model in clinical practice. American Journal of Nursing, 107, 50-58. 14. Hendrich, A. L., Bender, P. S., & Nyhuis, A. (2003). Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients. Applied Nursing Research, 16. 15. Kolin, M., Minnier, T., Hale, K., Martin, S. C., & Thompson, L. E. (2010). Fall Initiatives Redesigning Best Practice. The Journal of Nursing Administration, 40, 384-391. 16. Lloyd, T. (2011). Creation of a Multi-Interventional Fall-Prevention Program Using Evidence-Based Practice to Identify High-Risk Units and Tailor Interventions. Orthopaedic Nursing, 30, 249-257.
  • 39. 17. Lovallo, C., Rolandi, S., Rossetti, A. M., & Lasignani, M. (2009). Accidental falls in hospital inpatients: evaluation of sensitivity and specificity of two risk assessment tools. Journal of Advanced Nursing, 66, 690-696. 18. Main Health (2012). A Matter of Balance Volunteer Lay Leader Model Evidence-Based Falls Management Program for Older Adults. In Partnership for Healthy Aging (pp. 1-5). Retrieved from http://www.mainehealth.org 19. McHugh, M. D., Kelly, L. A., Sloane, D. M., & Aiken, L. H. (2010). Contradicting Fears, California’s Nurse-To-Patient Mandate Did Not Reduce The Skill Level Of The Nursing Workforce In Hospitals. Health Affairs, 30, 1299-1306. 20. Panel on Prevention of Falls in Older Persons (2010). Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. In American Geriatrics Society and British Geriatrics Society (1-10). New York: American Geriatrics Society. 21. Poe, S. S., Cvach, M., Dawson, P. B., Straus, H., & Hill, E. E. (2007). The Johns Hopkins Fall Risk Assessment Tool Post implementation Evaluation. Journal of Nursing Care Quality , 22, 293-298. 22. Poe, S. S., Cvach, M. M., Gartrell, D. G., Radzik, B. R., & Joy, T. L. (2005). An Evidence-based Approach to Fall Risk Assessment, Prevention, and Management Lessons Learned. Journal of Nursing Care Quality , 20, 107-116. 23. RAND. (2003). Evidence Report and Evidence-Based Recommendations Falls Prevention Interventions in the Medicare Population (500- 98-0281). Los Angeles, CA: Southern California Evidence-Based Practice Center.
  • 40. 24. Ryan, J. J., McCloy, C., Rundquist, P., Srinivansan, V., & Laird, R. (2011). Fall Risk Assessment Among Older Adults With Mild Alzheimer Disease. Journal of Geriatric Physical Therapy, 34, 19-27. 25. Scaf-Klomp, W., Sanderman, R., Ormel, J., I, G., & Kempen, M. (2003). Depression in older people after fall-related injuries: a prospective study. Age and Ageing, 32, 88-94. 26. Schwendimann, R., Buhler, H., GEEST, S. D., & Milisen, K. (2006). Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Services Research , 69, 1-7. 27. Sommers-Flanagan, J., & Sommers-Flanagan, R. (2009). Clinical Interviewing (4th ed.). Hoboken, New Jersey: John Wiley & Sons. 28. Spoelstra, S. L., Given, B. A., & Given, C. W. (2011). Fall Prevention in Hospitals: An Integrative Review. Clinical Nursing Research, 1- 21. 29. Stalhandske, E., Mills, P., Quigley, P., Neily, J., & Bagian, J. (2004). VHA’s National Falls Collaborative and Prevention Programs. In National Center for Patient Safety (U.S. Department of Veterans Affairs ). Retrieved from http://www.patientsafety.gov/ 30. Stubbs, B. (2011). Falls in older adult psychiatric patients: equipping nurses with knowledge to make a difference. Journal of Psychiatric and Mental Health Nursing, 18, 457-462. 31. Tzeng, H. (2011). Nurses’ Caring Attitude: Fall Prevention Program Implementation as an Example of Its Importance. Nursing Forum, 46, 137-145. 32. U.S. Department of Veterans Affairs (2004). Interventions. In National Center for Patient Safety 2004 Falls Toolkit (). [http://www.patientsafety.gov]. Retrieved from

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