ANA OJIN is a peer-reviewed, online publication that addresses current topics affecting nursing practice, research, education, and the wider health care sector.

Find Out More...

Letter to the Editor

  • A critical element of preparing competent nursing students, not mentioned in "Crisis in Competency: A Defining Moment in Nursing Education", is the need to eliminate barriers to recruiting and retaining nurse educators still engaging in clinical practice.

  • Continue Reading...
    View all Letters...

Hospital-Based Fall Program Measurement and Improvement in High Reliability Organizations

m Bookmark and Share

Patricia A. Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP
Susan V. White, PhD, RN, CPHQ, FNAHQ, NEA-BC


Falls and fall injuries in hospitals are the most frequently reported adverse event among adults in the inpatient setting. Advancing measurement and improvement around falls prevention in the hospital is important as falls are a nurse sensitive measure and nurses play a key role in this component of patient care. A framework for applying the concepts of high reliability organizations to falls prevention programs is described, including discussion of the core characteristics of such a model and determining the impact at the patient, unit, and organizational level. This article showcases the components of a patient safety culture and the integration of these components with fall prevention, the role of nurses, and high reliability.

Citation: Quigley, P., White, S., (May 31, 2013) "Hospital-Based Fall Program Measurement and Improvement in High Reliability Organizations" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 5.

DOI: 10.3912/OJIN.Vol18No02Man05

Key words: Falls, measurement, nurse sensitive, High Reliability Organizations

Advancing measurement and improvement around falls prevention in the hospital is important as falls are a nurse sensitive measure and nurses play a key role in this component of patient care (AHRQ, 2012; Quigley, Neily, Watson, Strobel, & Wright, 2007; White, 2012). A framework for applying the concepts of high reliability organizations to falls prevention programs is described including determining the impact at the patient, unit, and organizational level. This article showcases the components of a patient safety culture and the integration of these components with fall prevention, role of nurses, and high reliability.

Falls and Fall Injury in Hospitals

Fall measurements have been identified as important to patient outcomes by several organizations based on the fact that falls are the most frequently reported adverse patient event among adults in the inpatient setting (Currie, 2008). Fall measurements have been identified as important to patient outcomes by several organizations... However, not all falls can be prevented. Falls can be categorized as anticipated, accidental, and physiological (Morse, 1997). Regardless of the type of fall, injuries can occur in all types of falls, and programs are designed to prevent falls as well as fall injuries.

Falls represent a major public health problem around the world. In the hospital setting, falls continue to be the number one adverse event with approximately 3-20% of inpatients falling at least once during their hospitalization. Of those, 30 to 51% of falls in hospitals result in some injury (Oliver, Healey, & Haines, 2010). Of these, 6 to 44% experience similar types of injury (e.g., fracture, subdural hematomas, or excessive bleeding) that may lead to death. Adjusted to 2010 dollars, one fall without serious injury costs hospitals an additional $3,500, while patients with more than 2 falls without serious injury have increased costs of $16,500. Falls with serious injury are the costliest with additional costs to hospitals of $27,000 (Wu, Keeler, Rubenstein, Maglione, & Shekelle, 2010). Many interventions to prevent falls and fall-related injuries have been tested. However, they require multidisciplinary support for program adoption and reliable implementation for specific at-risk and vulnerable subpopulations, such as the frail elderly and those at risk for injury (Oliver et al, 2010; Spoelstra, Given & Given, 2012). The following organizations are key stakeholders in falls and data prevention.

Center for Medicare and Medicaid Services(CMS) and Hospital Falls Data

Improving the quality of care and patient safety is a priority for government, payers, and providers, and falls are one example of concern to these health care organizations. In 2008, the Center for Medicare and Medicaid Services identified falls as a Hospital Acquired Condition. In 2008, the Center for Medicare and Medicaid Services (CMS) identified falls as a Hospital Acquired Condition (HAC). An HAC is a complication or comorbidity (CC) or major complication or comorbidity (MCC) that occurs as a consequence of hospitalization and is high volume and/or high cost, and be reasonably preventable using evidence-based guidelines (Radey & LaBresh, 2012). CMS has identified eight HACs from billing data, and falls and trauma including fractures, dislocations, and intracranial injuries are all categorized as HACs, listed in Table 1. CMS will no longer cover the cost of care as a consequence of an inpatient fall based on the presumption that falls are preventable by the organization (CMS, 2009).

The Joint Commission (TJC

Furthermore, TJC (2013) requires accredited hospitals to conduct fall risk assessments for hospitalized patients to identify patients’ risk for falls so that prevention measures can be implemented into the plan of care (The Joint Commission, 2013). TJC began to monitor sentinel events in 1995, and through the end of 2012, there have been 659 fall related events which resulted in death or permanent loss of function that were voluntarily reported as a sentinel event. This number reflects voluntary reporting and represents only a small portion of actual events. The actual number is unknown but is most likely much greater, attesting to the importance of fall prevention interventions. What is clear is that patients are still falling in hospitals and experiencing injury (The Joint Commission, n.d.). The depth and breadth of program evaluation must be expanded; applying the concepts from high reliability organizations can assist in better results. Dr. Mark Chassin, current President of TJC, and Dr. Jerod Loeb, executive vice president, conclude that the health care industry can achieve excellence in safety and quality through three components that support high reliability – leadership, safety culture, and robust process improvement (Chassin & Loeb, 2011). Through these processes, care can be made more effective, efficient, and less vulnerable to failure which may result in patient harm.

National Database for Nursing Quality Indicators (NDNQI) and Falls Data

Most hospitals collect data on falls for internal analysis, and many also participate in external databases such as the National Database for Nursing Quality Indicators (NDNQI) as part of their Magnet™ designation quality improvement program (American Nurses Association, 2010) or part of their general improvement program as this provides an external benchmark comparison. NDNQI reports provide internal and external comparison with like-units in like-facilities...quality indicators link nursing care to patient outcomes. Through benchmark comparison with similar types of nursing units, organizations are then able to assess their performance and determine opportunities for improvement. However, fall risk assessment and analysis of fall rates and injury rates only serves as the foundation for program measurement and evaluation.

As part of patient safety programs, clinicians, administrators, and risk managers collaborate to set realistic target goals for reducing rates of falls and fall-related injuries. They review, compare, and analyze epidemiological data that is both population and setting-specific, using both internal and external data. The American Nurses' Association's (ANA) National Database of Nursing Quality Indicators® (NDNQI®) enables comparison of injury fall rates based on severity of injury and other nurse sensitive indicators for participating acute care organizations (American Nurses Association, 2004-2006). NDNQI reports provide internal and external comparison with like-units in like-facilities including bed size, teaching status, Magnet status, and other parameters.

ANA quality indicators link nursing care to patient outcomes. Patient injury rate, noted to be most often caused by falls, was promoted as a nurse sensitive indicator, a measure of quality that links patient outcomes with availability and quality of professional nursing services (ANA, 1995). ANA has asserted nurses' responsibility to assess patients' risk for falls and injury; design and implement risk reduction care plans; and evaluate effectiveness of clinical fall prevention programs. ANA also recommended consistency of data reporting, measurement and analysis. Because of these efforts, participating NDNQI hospitals can evaluate the efficacy of their processes tracked by NDNQI, such as the use of valid and reliable fall risk screening tools. Moreover, standardized post fall analysis and rates are available to analyze patient safety programs and clinical effectiveness. Examples of fall-related data specific to care processes and outcomes provided by NDNQI are listed in Table 1.

National Quality Forum (NQF) and Falls Data

Injury falls are often termed as “never events” by the National Quality Forum (NQF). These falls are associated with increased morbidity/mortality rates and also impact reimbursement. As falls are a nurse sensitive measure, nurses play a pivotal role in the prevention of falls and fall injuries. The NQF developed 28 never events that should never occur to a patient while being cared for in a healthcare facility. Process and outcome fall-related measures are listed in Table 2. Additionally, NQF captures data on death or serious disability associated with a fall as one of those never events. Recently, the NQF endorsed the ANA’s NDNQI quality measures to improve patient safety in hospitals - patient fall rate and patient falls with injury (National Quality Forum, 2013).

Agency for Healthcare Research and Quality (AHRQ) and Fall Fracture

...fall prevention programs must include multicomponent interventions to reduce falls, which are ready for adoption now. The AHRQ provides numerous tools associated with falls prevention, but it is primarily viewed as a resource for evidence based practice. Specific to falls, AHRQ has defined a patient safety indicator for measuring the rate of postoperative hip fractures (Table 1). In their recent publication of 22 safety practices on falls, the authors note that “attention to multiple risk factors is more effective than an intervention that targets any single risk factor,” creating a multi-systematic fall prevention model which is consistent with a systems approach to improving safety and reliability of care (AHRQ, 2013a). Thus, fall prevention programs must include multicomponent interventions to reduce falls, which are ready for adoption now (Miake-Lye, Hempel, Ganz, & Shekelle, 2013).

Table 1 illustrates how falls and injury measures are defined by the organizations described in this article. A comparison of these major organizations and process and outcomes data specific to falls and injury rates reveals differences as well as similarities in measurement.

Table 1. Comparison of Fall and Injury Measures by Organizations


NQF “Never Event”

CMS Hospital Acquired Conditions (HACs)

AHRQ Patient Safety Indicator



Fall risk assessment

*Time since last fall risk assessment


Fall risk assessment






Fall risk assessment defined by the organization (TJC PC.01.02.08)


Fall rates

Fall injury rates

Fall assessment

Repeat fall rates

Injury rates of moderate and higher Injury level

Percent of patients who fell


Fall rate

Fall injury rate

*Patient death or serious disability associated with a fall while being cared for in a healthcare facility


Falls and trauma,including:



-Intracranial injuries

(Must have occurred in acute hospital)


Postoperative hip fracture rate (PSI #08)


Data presented to demonstrate improvement defined by the organization (TJC.PI.03.01.01)


High Reliability Organizations: Current Model

The trend to advance patient safety and quality in health care organizations is based on implementing the concepts of high reliability organizations (HRO). Experts (Pronovost et al., 2006; Weick & Sutcliffe, 2007) agree that high reliability organizations are those that achieve a high degree of safety or reliability despite dangerous or hazardous conditions. The trend to advance patient safety and quality in health care organizations is based on implementing the concepts of high reliability organizations.The nuclear and airline industries are noted as some of the most hazardous industries and have often been cited for their defect-free or error-free operations for long periods of time. Case studies of the Three Mile Island nuclear incident, the Challenger and Columbia explosions, the Tenerife air crash and other events examine how these events occurred and the similarities in these high risk situations, giving rise to studying and defining reliability in hazardous organizations. This study of HROs can lead to organizational behaviors that demonstrate anticipation, resilience, and constant improvement (Weick & Sutcliffe, 2007).

Based on the HRO model, many compare health care organizations as aspiring to emulate characteristics of other HROs to minimize errors and achieve exceptional performance in patient safety and quality. There are great opportunities to improve by moving in this direction. Some studies indicate that core processes in health care are defective 50% of the time and patients receive only about 55% of the appropriate care when entering the health care system (McGlynn et al., 2003; Resar, 2006).

Efforts to lead this improvement movement come from a variety of sources such as those noted earlier (e.g., CMS HACs for the Hospital Inpatient Quality Reporting Program, TJC Center for Transforming Healthcare with Targeted Solutions Tools, AHRQ, NDNQI measurement system, and NQF “never events”). Each of these organizations and/or initiatives promotes error or defect free health care through interventions and measures that support this goal. There is clearly a unified goal across organizations to support a culture for patient safety and quality of care through continuous improvement and systems, which must also include measurement systems.

HRO Core Characteristics

The core characteristics of HRO have been well documented in the literature from the work of Weick and Sutcliffe (2001; 2007) on creating a culture and processes that reduce system failures and respond effectively when failures/errors do occur. These characteristics include:

  • Sensitivity to operations - a constant awareness by leaders and staff of the state of systems and processes that affect patient care so that risks can be noted and prevented.
  • Reluctance to simplify - the ability to streamline processes but not oversimplify explanations for adverse events in order to understand the true reasons why patients are placed at risk.
  • Preoccupation with failure - a focus to thoroughly examine root causes for a problem; make improvements; and view near misses as evidence of systems that should be improved to decrease potential harm to patients and not as proof that the system has effective safeguards.
  • Deference to expertise - leaders listen to and respond to others’ insights, including direct care clinicians, patients, and family members; leaders listen to the insights of staff who know how processes work and the risks patients really face. Weick and Sutcliffe (2007) called this “knowledge before hierarchy.”
  • Resilience - leaders and staff are trained and prepared in how to respond when system failures do occur.

The focus of a HRO is safe reliable performance.The focus of a HRO is safe reliable performance. By embedding the core characteristics into the fabric of the organization, leaders build expectations into the daily organizational roles, routines, and strategies. These expectations create order and predictability around processes and practices that allow members of the organization to manage unexpected events through “mindfulness.” Mindfulness is greater than situational awareness; it is a greater awareness of discriminatory detail that provides organizations with the “big picture.” It helps identify early warning signs that some unexpected event is unfolding and action needs to be taken. This mindfulness increases alertness and readiness to potential problem areas in the here and now. HRO principles steer people toward mindful practices that encourage timely response toward unexpected events. If an event does occur then the person is mentally ready to work on recovery and minimize disruption from the event (Weick & Sutcliffe, 2007).

Weick and Sutcliffe (2001; 2007) described three types of unexpected events that require mindfulness to ensure safe reliable performance:

  1. When an event that was expected to happen fails to occur
  2. When an event that was not expected to happen does happen
  3. When an event that was simply un-thought of happens.

HRO practices can be applied to a falls prevention program, including how to deal with unexpected events. For example in HROs, every event and near miss is reviewed with performance evaluated. In a falls prevention program, each fall is reviewed; near falls are rarely reviewed. In HROs, multiple checks in multiple ways are completed. In a falls prevention program, there are multiple fall interventions and multiple methods of implementation such as purposeful rounds, environmental rounds, and interdisciplinary care planning. In HROs, continuous communication is the norm. In a falls prevention program, frequent communication occurs such as hand-off communication about fall risk factors and related interventions; signage to communicate patients who are known fallers and those at risk for serious to moderate injury; pre-shift and post fall communication huddles; and interdepartmental handoff detailing fall; and injury risk factors and protective interventions.

HRO practices can be applied to a falls prevention program... In HROs, the importance of routines and predictable behaviors is emphasized. In a falls prevention program, routines for fall risk assessment and reassessment, as well as routine interventions, are standardized into practice. In HROs, it is a necessity to improvise or bounce back after an event (Weick & Sutcliffe, 2007). In a falls prevention program, one must quickly assess the patient post fall in order to effect immediate treatment or a change in interventions needed to prevent a reoccurrence.

Riley (2009) described four tools that support the design and implementation of processes for high reliability: process maps, control charts, a model for improvement, and health care bundles. All four of these tools can be applied in fall and injury prevention program evaluation. Process maps can be used to describe the steps in assessment, reassessment, interventions, and evaluation of falls. They can also be used to track timelines for implementation of interventions from idea generation through implementation and evaluation. Control charts can be used to analyze fall rates overall; type of fall; repeat falls; fall injury and level of severity;  number of days between preventable falls; and serious injury; within defined upper and lower control limits over time to determine if the process is stable. Several models of improvement can be found in the literature to support improving the process to reduce fall and injury rates. The most common model is the Plan-Do-Study-Act model or the Institute for Healthcare Improvement (IHI) model for improvement (Langley, Nolan, Nolan, Norman, & Provost, 2009). Lastly, a fall bundle of interventions can be applied based on risk, population, and setting.

Components of a Safe Culture

...a HRO staff adopts a style of functioning that promotes continuous learning. The concepts of a HRO cannot be fully separated from the components of a safe culture. There are different dimensions or ways to perceive how different factors contribute to patient safety and quality within an organization. For example, a HRO staff adopts a style of functioning that promotes continuous learning. When these behaviors have not been adopted, it is more difficult to create reliable performance and detecting failures is more likely to not occur and leads to more significant adverse events. When the culture has not embraced the HRO concepts and experienced a failure, the following have been frequently found (Weick & Sutcliffe, 2007):

  • Recent changes in supervision
  • Issues delegated without follow-up
  • Lack of a questioning attitude
  • Missed steps in a procedure
  • People not on the same page
  • Staff spread thin
  • Distraction from schedule pressure

The AHRQ (2013a) recent publication of 22 safety practices, in which falls prevention was presented, also identified the seven elements listed below that contributed to success in a falls prevention program. These elements have similarities to other aspects of a safe culture.

  • Leadership support
  • Engagement of front line clinical staff
  • Multidisciplinary committees
  • Pilot test of interventions
  • Informational technology system for data collection and management
  • Changing the prevailing attitude that “falls are inevitable”
  • Adequate time for education and training 

Analysis of errors identifies many similar factors that contribute to error-prone situations (Weick & Sutcliffe, 2001). In reviewing those components that most strongly support a culture of patient safety, several emerge including leadership, teamwork, evidence based practices, and measurement and reporting systems (Byers & White, 2004; IOM, 1999; 2001b; Sherwood & Barnsteiner, 2012). While these are not the only factors that support a safe culture, these four factors with support for a strong impact will be discussed in this section.


The essential components of a safe culture begin with leadership. Key leaders are aware that the health care environment is one of risk and they seek to reduce this risk by aligning the vision, mission, and fiscal and human resources with frontline direct care (Beaudin & Pelletier, 2012; IOM, 1999; Sherwood & Barnsteiner, 2012). Nurse leaders recognize how strong nursing processes, interventions, and evaluations of care through measurement systems support a patient safe culture and reduce risk and harm to patients. An example of reducing risk and harm to patients is a program designed to prevent falls and injuries from falls. Nurses hold key leadership positions and clinical practice roles, vital to shaping high performance fall program outcomes at the organizational, unit, and patient levels through leading/coordinating multi-component individualized care planning with interdisciplinary teams. The need for leadership is noted as the first step in almost any improvement initiative in order to garner resources and support for implementation across the organization (White, 2011).

Team Work

Safe culture is further strengthened by strong interdisciplinary teams, which includes collaboration and cooperation among leaders, nursing staff, and staff from other disciplines. Safe culture is further strengthened by strong interdisciplinary teams... Teams should apply evidence-based practices to improve standardization and reduce unwanted variation in processes. Effective teams are manifested by open communication whereby leaders facilitate each member' ability to speak up on behalf of a patient, and in which teams have a clear vision and purpose of the roles of each member. Teams need regular feedback and should be capable of correcting behaviors that do not promote patient safety. Members in a strong safety culture demonstrate clear communication among all staff and this communication is frequent. Frequent, open communication engenders trust among members, and there is ongoing learning in which healthcare system leaders gain wisdom from mistakes and seek to continually improve processes and performance. Safe culture is one that views errors as system failures rather than individual failures (Beaudin & Pelletier, 2012; Byers & White, 2004; IOM, 1999; Riley, 2008). The entire focus is patient-centered; safety and quality of care in the health care system is centered on patients and families.

Evidence –Based Practice

The role of nursing in using HRO concepts to support safe patient care in fall prevention and fall injury prevention includes a strategy for the implementation of evidence-based practice (EBP). EBP will promote standardization, reduce variation, and strengthen the focus on preoccupation with failure. In this example, the failure would be a fall, and even more serious is a fall with injury.

Evidence regarding major factors that reduce errors in health care systems targets effective communication and trans-disciplinary work. Evidence for the most successful fall prevention programs suggests multifactorial and interdisciplinary components (Oliver et al., 2010). In HROs, a set of barriers to protect the patient from harm is a hallmark feature. In a multifactorial falls prevention program, there will be many systematic barriers established to reduce the risk of a fall and injury. Evidence based interventions will improve standardization in processes and decrease variation (Oliver et al, 2010; Miake-Lye et al., 2013; Radly & LaBresh, 2012; Sepolstra et al., 2012). This is seen in fall prevention programs in which fall bundles to prevent falls and injuries allow standardized application of evidence such as risk assessment using a valid and reliable tool. Improved systems design includes use of checklists, decreasing interruptions, preventing fatigue, avoiding task saturation, reducing clinician stress, and improving environmental conditions. These design elements can be found in fall prevention programs such as lists of possible fall prevention interventions and fall injury interventions. Modifications and improvements to environmental conditions that reduce the risk of falls may include lighting; flooring to absorb impact of a fall; handrails to assist with ambulation; elimination of trip hazards with raised thresholds, sloping ledges, and curbs; and marking trip hazards to increase their visibility (AHRQ, 2013; NCPS, 2004).

In 2013, AHRQ published 22 safe practices, one of which targeted preventing in-facility falls (Ganz, Huang, Saliba, & Shier 2013). Because most fall prevention programs are multifactorial, the best the authors could do in identifying and reviewing the evidence was to describe interventions that have been evaluated, including the following:

  • Post fall review
  • Patient education
  • Staff education
  • Footwear advice
  • Scheduled and supervised toileting
  • Medication review

The AHRQ toolkit for falls provides resources and tools that enable hospitals to monitor and evaluate structures, processes and outcomes (AHRQ, 2013). This toolkit draws on a systematic review of current literature and evidence as well as expert opinion. Where the evidence exists it is cited, but where the evidence is not clear the use of experts and clinical experience are presented. Additionally, the Veterans Administration National Center for Patient Safety (VA NCPS) Falls Toolkit supports evidence based practice for falls prevention (NCPS, 2004).

Measurement and Reporting Systems

A balancing measure might be the number and cost of sitters associated with the program or staff injury associated with trying to support patients in an assisted fall. Measurement systems support a patient safety culture (IOM, 1999; IOM, 2001b). Measurement systems include several types of measures. Donabedian (2005) is known for his structure, process, and outcome measures. Additionally, there are balancing measures. These measures provide a method of assessing the impact of a process not only on the desired measure of interest, but also on other areas which may be positive or negative. In Table 2, an example of each type of measure associated with a fall and injury prevention program is presented. For example, the fall prevention program could include use of sitters to monitor patients who have fallen to prevent repeat falls. The primary outcome measure is fall rate per 1000 patient days. A balancing measure might be the number and cost of sitters associated with the program or staff injury associated with trying to support patients in an assisted fall.

Injury analysis by severity levels enables clinical and administrative staff to profile both vulnerability of patients and effectiveness of patient safety programs. For example, if 70% of elderly patients who sustain lateral falls incur hip fractures, one might suspect a large prevalence of osteoporosis. If one unit exceeds other units on their monthly fall rates and has higher injury rates, one would target that unit for evaluation and intervention. In addition to tracking injury and injury severity rates, another performance indicator is the number of days between major injuries. Increases in the length of time between major injuries are another indicator of the effectiveness of fall reduction programs.

Table 2 illustrates Donabedian’s framework for measurement including structure, process, outcome, and balancing measures. Examples of these measures in a fall prevention program are presented as to the type of measure. Nurses in a HRO will continue to examine their processes and focus on improvement to reduce risk of falls within their healthcare setting. As experts on fall and fall injury prevention, nurses are critical to lead teams that develop, implement, and evaluate programs.

Table 2. Types of Measures and Fall and Injury Prevention Program Examples


Fall Prevention Program Examples

Structure Measures

Nurse staffing on unit (Nurse to patient ratio)

Number and percent of professional nurses (RNs) and other nursing staff (e.g., sitters)

Interdisciplinary members on falls team

Injury reduction products

Fall present on admission (POA)

Fall Injury POA

Post fall huddle

Process Measures

Fall risk screening specific to anticipated physiological fall

Fall risk assessment/ reassessment (Number of patients identified as high, moderate, low risk to fall)

Fall injury risk/history assessment (Number of patients identified as high, moderate, low risk to incur a fall injury)

Fall prevention interventions (e.g. no slip socks, assistive devices, handrails, low bed, chair and bed exit alarms)

Fall injury prevention interventions (e.g. hip pads, floor mats)

Completion of hourly rounds

Assisted falls (unassisted fall)

Post fall assessment

Outcome Measures

Fall rate per 1000 patient days (by type of fall)

Fall injury rate per 1000 patient days (by severity)

Percent of fall injuries that are major injuries

Days between major fall injury

Repeat fall by type of fall

Repeat fall by patient

Reduction in modifiable fall risk factors

Balancing Measures

Use of sitters for fall prevention (e.g., number, cost)

Use of restraints to prevent patient from getting out of bed and falling

Additional staff required for hourly rounds

Staff injury (associated with assisted fall)

Determining the Impact of Safe Care: Nurses’ Role at Multiple Organizational Levels

Nurses play a key role in ensuring quality and patient safety in health care. Nurses are most likely to spend the greatest amount of time with patients and are in a strong position to monitor and mitigate risks and improve patient outcomes. While nurses may impact numerous clinical processes and outcomes, the example of falls and injury prevention as nurse sensitive measures will be reviewed as an exemplar framework for demonstrating safe, quality care at the organization, unit, and patient level. Table 3 details critical contributions of nurses to program effectiveness. This framework enables nurses to determine the impact of safe care at multiple levels. Table 3 describes the role of nurses within hospital organizations to demonstrate competency and functions that support HROs. Sherwood and Barnsteiner (2012) summarize the Robert Wood Johnson Foundation Quality and Safety Education for Nurses (QSEN) framework that was developed to transform nursing education to integrate competencies specifically for quality and safety. This framework will begin to shape prelicensure nursing skills to ensure the future generations of nurses are better able to support HROs. Elements in Table 3 support the current workforce changes important to HROs.

In addition, Riley (2008) made recommendations for nurse leaders to ensure that high reliability is embedded as a core characteristic of the organization. These recommendations were translated into a practical application for a falls prevention program in Table 4.

Table 3. High Reliability Organizations (HROs) and Role of Nurses in Fall and Injury Prevention Program

Key Elements of HRO

Role of Nurses

Organizational Level

Critical Contributions

Team Training/Competency Validation

Training of nurses on falls prevention program, EBP on interventions, rounding methods and elements

Competency assessment in EBP and nursing interventions and practices to prevent falls and injuries

Design Care Processes to reduce risk and harm

Fall prevention and fall injury prevention processes integrated into nursing process (assessment, reassessment, planning, tailored interventions, patient education, evaluation of intervention effectiveness)

Organization wide program with customization for selected populations (e.g. pediatrics, geriatrics) and settings (e.g. acute care, long term care, home care)

Surveillance via standardized safety rounds (hourly)

Core Processes Understood and Measured

Measurement system for a fall prevention program (see Table 2)

    Structure Measures
    Process Measures
    Outcome Measures
    Balancing Measures

Error Proof the Organization

Fall injury prevention program

Implement multiple tools/methods to prevent this "error" or defect

Process Standardization

Fall bundles implementation, measurement, and evaluation

Nurses in all roles and at all levels of the organization have a shared and integrated responsibility to apply concepts of HROs to patient safety programs, such as fall and injury prevention. The HRO framework is applied to nursing process specific to nurses in administrative and direct care roles in Table 4. While the literature continues to discuss how the concepts of HROs can be applied in health care organizations, less is specifically discussed within nursing in order to integrate the concepts into practice at the patient, unit, and organization level. Table 4 begins to compare and contrast the roles of a nurse leader at the organizational level, such as Chief Nurse or Vice President of Patient Care Services, in setting the cultural tone, providing the resources, and setting expectations about measures. This role has been specifically addressed by Kerfoot (2007) and Riley (2008) for nurse leaders.

More broadly, the Institute of Medicine (IOM) has highlighted the importance of patient safety (1999; 2001; 2004) and recently focused on the role of nurses in ensuring patient safety in health care (IOM, 2004). If nurse leaders create the culture, nurse managers at the unit level sustain this culture through consistency and reliability across units. This includes the application of evidence-based practices across units, such as fall prevention interventions,and the measurement system for a falls prevention program that standardizes definitions, interventions, tools, and reports. Kerfoot (2007) notes that through a shared leadership structure, nurse managers are the “powerhouse” to get things done. “If full compliance with this procedure on all units at all times is lacking, high-reliability practices and flawless execution are impossible” (Kerfoot, 2007, p.274). At the nurse-patient interface, the strongest defensive barriers to protect the patient from injury (such as falls and fall injuries) come from the system of layers of protection (Riley, 2008), which are well described in Reaon’s (1990) work on systems and errors and the concept of the “Swiss Cheese”.

Table 4. Translating HRO Concepts to Nursing Practice

HRO Concept

Organization Level (macrosystem)

Unit Level (microsystem)

Patient Level


Nurse Leader

Nurse Manager

Nurse at Bedside


Create a safe culture for reporting errors without blame

Support culture of open communication

Support just culture in which systems and process issues are understood as primary causes of errors vs. individuals

Translate the culture for reporting and error analysis to the unit level

Report falls and injuries (without fear)

Communicate patient-reported and nurse-assessed risk factors

Communicate and determine interventions post fall


Support staff to attend training

Support a shared leadership structure (e.g. shared governance) in which best practices are shared, and fall prevention program design includes front line nurses and clinical experts

Support unit and interdisciplinary collaboration and use of EBP

Incorporate program/ interventions into daily existing workflow

Identify current EBP on falls prevention

Involve patient and family in education and shared decision making re- interventions


Provide resources for fall prevention program (e.g. assistive devices, mats, hip protectors, exit alarms, environmental adjustments)

Provide appropriate nursing staff to implement falls prevention program

Allow time for safety rounds

Apply resources on the unit based on type of unit and patient population and patient needs

Design and implement staffing patterns to support the program

Implement specific tools, equipment and time into practice for falls prevention

Conduct safety rounds


Support nurse manager/leader collaboration and consistency across nursing units for standardized reliable processes

Collaborate with nurse managers of other units and with managers of other disciplines to create interdisciplinary team approach to falls prevention

Be a unit based champion for falls prevention

Participate on team huddles and/or committees in which fall prevention program is addressed or in huddles post fall

Fall and Injury

Expand data analysis measures to include:

-Fall rate

-Fall rate by type of fall

-Injury rate

-Injury rate by severity

-Percent of patients who fell

-Percent of patients at high risk for fall

-Percent of patients who fell more than once

-Percent of patients at risk for moderate to serious injury

-Percent of patients with fall POA

-Percent of patients with fall Injury history POA

Establish system level measures and measurement systems

Implement fall and injury protocols specific to patients with history of falls and type of injury

Fall rounds to individualized patient care plans

Purposeful rounding (linked to type of fall)

Post fall huddles

Collection of data and reporting of system measures

Collect daily fall and injury data for reporting

Safety of Care


-Percent of patients at high risk for falls that did not fall

-Percent of patients with fall injury history POA who did not fall

-Percent of patients with fall and injury history POA who did not fall

Support for consistent reliable results





In 2007, TJC provided guidance to hospital leadership to evaluate fall prevention programs. Knowledge of fall prevention program deployment and evaluation using a high reliability model and statistical analysis can help nurses design and test effectiveness of fall and injury prevention programs.This fall program evaluation included analysis of structures (e.g., nurse staffing, nursing skill mix, and interdisciplinary participation) and processes (e.g., timeliness of assessment, implementation of interventions, involvement of patients and caregivers) of an organization’s falls prevention programs, which then enables analysis of outcomes – falls, injury from falls, and cost of falls. All organizations, TJC, NDNQI, NQF, and AHRQ, emphasize nurses’ contribution to patient safety by assessing fall risk and designing patient-specific fall prevention interventions that reduce risk and prevent falls and fall-related injury.

Nurses’ leadership and clinical judgment is critical and affirmed (IOM 2003). However, nurse organizational leaders must expand program evaluation beyond the point of care at the patient level, to include key attributes at unit and organizational levels. Knowledge of fall prevention program deployment and evaluation using a high reliability model and statistical analysis can help nurses design and test effectiveness of fall and injury prevention programs (Quigley et al., 2007). Organization, unit, and point of care infrastructure, capacity, and interventions can be tracked and evaluated to identify best system practices.

For example, if a hospital determines that 30% of falls resulted in injury, they must examine environmental hazards that contribute to injury, organizational infrastructure, and capacity to protect patients from injury. Hospital leaders must examine organizational and unit-level infrastructure and capacity to reduce trauma when a patient falls. They must also examine strategies to eliminate sharp edges, objects able to be struck as a patient falls from one level to another, and blunt force trauma from unprotected flooring in rooms, bathrooms, and showers. This rate of injury is higher than published literature; the rate of those who fall with some injury is 30 to 51% (Oliver et al., 2010).

In contrast, if a hospital determines that 5% of the falls with injury are moderate to serious, the hospital must examine its fall injury reduction program, focusing on risk for moderate to serious injury upon patient admission. The hospital should implement multifactorial interventions to protect vulnerable patients with strategies advised by the Department of Veterans Affairs and the Institute for Healthcare Improvement TCAB (Boushon et al., 2012; Quigley et al., 2010). Risk for serious injury is separate from risk for fall, and is based on known clinical conditions, such as osteoporosis and anticoagulation. Interventions to protect from injury are separate from the interventions to reduce fall risk factors.

Meaningful use of program evaluation that includes in-depth data as core data, enhanced by additional data analysis, will help nurses and hospital staff evaluate the impact of interventions. While these examples are hospital-level, this expanded analysis could occur at the unit level and be compared across units or based on specific populations. Hospitals can decide on the depth and breadth of program evaluation as a HRO.

To be a high reliability organization, hospitals must analyze falls by type of fall and link interventions to type of fall at all levels: organization, unit, and patient care, targeting risks for physical injury in combination with fall prevention. Once systems are developed for fall rate tracking and internal comparison, organizations can both identify trends and compare rates to those from national databases. Fall rates should compare with similar populations. For example, fall rates for acute care units should be compared with those for other acute care units, those for an organization's dementia populations with similar populations. Additionally, fall rates should be analyzed by type of fall, defining preventable from unpreventable falls. Still, this aggregated data analysis is insufficient to evaluate interventions being implemented per level. Interventions to prevent accidental falls require infrastructure and capacity at the organization and unit levels in order to be implemented at the point of care. This same assertion exists for reduction of anticipated physiological falls.

Organizations must analyze effectiveness of fall and injury prevention programs that are unit-specific and population-based. The recommendations suggest that clinical, administrative, and risk management staff conduct in-depth data analysis and provide unit-specific feedback to staff regarding fall rates and fall related injury rates.

Protecting patients from falls and fall-related injuries requires shared responsibility. Thus, we propose a population-based model that includes both fall prevention and injury protection (Figure 1). This model could potentially mobilize changes on a large scale, produce a normative effect, and achieve a more permanent diffusion process, as suggested by McClure et al. (2009). The proposed model is specific for hospitals (and nursing home residents) and includes fall prevention and injury protection interventions at the organizational, unit, and patient level (illustrated in Figure 2).

Figure 1. Model for Fall Prevention and Injury Protection



Figure 2. Model for Fall Program Comparison [see full size pdf]


At this time, no hospital-based study has examined the effectiveness of both fall prevention and protection from injury nor estimated the relative weight of intervention components to outcomes (Oliver et al., 2010; Quigley et al., 2010). To be a high reliability organization, hospitals must analyze falls by type of fall and link interventions to type of fall at all levels: organization, unit, and patient care, targeting risks for physical injury in combination with fall prevention. The exact combination of interventions for specific populations must build on the assumption that all inpatients are at risk for falls, repeat falls, injury, and unfortunately death from a fall, in order to provide a protective approach and demonstrate high performing organizations


Increasing regulatory and reimbursement changes challenge the health care industry to reduce hospital adverse conditions. Extensive literature documents the burden of falls to individuals, healthcare organizations, and society. Falls are categorized as an adverse event and usually further classified as accidental. Increasing regulatory and reimbursement changes challenge the health care industry to reduce hospital adverse conditions. Yet the measurement systems utilized for performance remains at the aggregate level, not affording precise evaluation of program changes and measurement.

We assert that measurement must change by setting up program evaluation that examines organizational, unit, and patient level data. Our proposed model for program evaluation, applied in this article to a fall prevention program, enables robust evaluation and better depicts a high reliability organization (HRO). This model could be applied to any hospital adverse condition. We assert that a changed model such as the one described here would better support identification of best performance and showcase safe hospitals.

Disclaimer: This material is based upon work supported by the Department of Veterans Affairs. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.


Patricia A. Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP

Dr. Patricia Quigley, PhD, ARNP, CRRN, FAAN, FAANP, Associate Director, VISN 8 Patient Safety Center of Inquiry, is both a Clinical Nurse Specialist and a Nurse Practitioner in rehabilitation. Her contributions to patient safety, nursing, and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. As Associate Chief, Nursing Service for Research and nurse researcher, she is responsible for advancing nursing and interdisciplinary knowledge, skills, and capacity for the conduct of research and research translation. She leads an interdisciplinary clinical team in the development of evidence-based assessment tools and clinical guidelines related to assessing veterans’ risk for falls and fall-related injuries across multiple medical centers. Additionally, she provides on going consultation to the nursing staff, quality management, and patient safety coordinators for management of complex patients at risk for falls.

Susan V. White, PhD, RN, CPHQ, FNAHQ, NEA-BC

Dr. Susan V. White, PhD, RN, CPHQ, FNAHQ, NEA-BC, is the Chief of Quality Management at the Orlando VA Medical Center. Her current areas of responsibility include quality management, performance improvement, accreditation, patient safety, risk management, infection control, and credentialing and privileging. She has previously served as Magnet coordinator leading an organization to renewal of its designation. She has an extensive career in the healthcare field, including nursing administration, management, and clinical roles. Her work through various positions has included accreditation related activities, resources on quality initiatives, initiatives on clinical performance improvement and patient perception, educational programs, and patient safety. She is a member of multiple professional organizations and has served on several boards in the state including the Florida Center for Nursing.


Agency for Healthcare Research and Quality (AHRQ). (2012). Quality indicator user guide: Patient safety indicators (PSI) composite measures. Version 4.4. Contract No. HHSA290201200001C. Retrieved from:

Agency for Healthcare Research and Quality (AHRQ). (2013a). Preventing falls in hospitals. A toolkit for improving quality of care. In Making Health Care Safer II. Retrieved from:

Agency for Healthcare Research and Quality (AHRQ). (2013b). Making healthcare safer II: An updated critical analysis of the evidence for patient safety practices. Retreived from:

American Nurses Association. (1995). Nursing care report card for acute care. Washington, DC: American Nurses Publishing.

American Nurses Association. (2004-2006). Nursing database for nursing quality indicators. National Center for Nursing Quality. Retrieved from

American Nurses Association. (2010). National database of nursing quality indicators® (NDNQI®). Retrieved from

Beaudin, C. L, & Pelletier, L. R. (2012). Healthcare safety in Q solutions. (3rd Ed. ). Glenview, IL: NAHQ.

Boushon, B., Nielsen, G., Quigley, P., Rita, S., Rutherford, P., Taylor, J., … Rita, S. (2012). Transforming care at the bedside how-to guide: Reducing patient injuries from falls. Cambridge, MA: Institute for Healthcare Improvement.

Byers, J. F., & White, S. V. (Eds). (2004). Patient safety. Principles and practices. New York, NY: Springer Publishing Co.

Center for Medicare and Medicaid Services. (2009). Hospital acquired conditions. Retrieved from:

Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs 30(4), 559-68.

Currie, L. M. (2008). Fall and Injury Prevention. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. AHRQ Publication No. 08-0043. Retrieved from:

Dekker, S. (2011). Patient safety. A human factors approach. Boca Raton, FL: CRC Press.

Donabedian, A. (2005). Evaluating the quality of medical care. Milbank Quarterly, 83, 691–729. doi: 10.1111/j.1468-0009.2005.00397.x.

Ganz, D.A., Huang C, Saliba D, & Shier, V. (2013). Preventing falls in hospitals: A toolkit for improving quality of care. (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI Institute under Contract No. HHSA290201000017I TO #1.) AHRQ Publication No. 13-0015-EF. Rockville, MD: Agency for Healthcare Research and Quality.

[The] Joint Commission. (2013). The joint commission comprehensive accreditation and certification manual. Retrieved from:

[The] Joint Commission. (n.d.). Event type by year 1995 – Q4 2012. Retrieved from

Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Institute of Medicine. (2001a). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Institute of Medicine. (2001b). Envisioning the national health care quality report. Washington, DC: National Academy Press.

Institute of Medicine. (2003). Keeping patients safe:  Transforming the work environment of nurses. Washington, DC: National Academy Press. Available:

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment for nurses. Washington, DC: National Academy Press.

Institute of Medicine. (2011). The future of nursing:  Leading change, advancing health. Washington, DC: National Academy Press. Available:

Kerfoot, K. (2007). Reliability between nurse managers: The key to the high-reliability organization. MedSurg Nursing, 16(4), 273-274.

Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd Ed). San Francisco, CA: Jossey Bass.

McClure R.J., Turner C., Peel N., Spinks, A., Eakin, E., & Hughes, K. (2009). Population-based interventions for the prevention of fall-related injuries in older people. The Cochrane Collaboration. The Cochrane Library, 2, 1–23.

McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., & Kerr, E.A. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348(26), 2635-2645.

Melnyk, B. M. (2012). Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice. Nursing Administration Quarterly, 36(2), 127-135.

Miake-Lye, I. M., Hempel, S., Ganz, D., & Shekelle, P.G. (2013). Inpatient fall prevention programs as patient safety strategy: A systematic review. Annuals of Internal Medicine. Supplement, 158(5, Part 2). 390-397.

Morse, J. M. (1997). Preventing patient falls. Thousand Oaks, CA: Sage Publications.

National Center for Patient Safety (NCPS). (2004). Fall prevention toolkit. Retrieved at

National Quality Forum (2013) National quality forum, national voluntary consensus standards for nursing-sensitive care: An initial performance measure set. Retrieved from

Oliver, D., Healey, F., & Haines, T. (2010). Preventing falls and fall-related injuries in hospitals. Clinical Geriatric Medicine, 26, 645-692.

Pronovost, P.J., Berenholtz, S. M., Goeschel, C.A.,  Needham, D.M., Sexton, J.B., Thompson, D.A… Hunt, E. (2006). Creating high reliability in health care organizations. Health Services Research, 41(4p2), 1599-1617.

Quigley, P., Neily, J., Watson, M., Strobel, K., & Wright, M. (2007). Measuring fall program outcomes. OJIN: The Online Journal of Issues in Nursing, 12(2), 1-17. Retrieved from:

Quigley, P., Bulat, T., Kurtzman, E., Olney, R., Powell-Cope, G., & Rubenstein, L. (2010). Fall prevention and injury protection for nursing home residents. Journal of the American Medical Directors Association, 11(4). 284-293.

Radey, L.A., & LaBresh, K.A. (2012). Evidence-based guidelines for selected and previously considered hospital-acquired conditions. Centers for Medicare and Medicaid Innovation. (RTI Project Number 0209853.231.002.122)  Retrieved from

Reason, J. (1990). Human error. Cambridge, UK: Cambridge University Press.

Resar, R.K. (2006).   Making noncatastrophic health care processes reliable: Learning to walk before running in creating high-reliability organizations. Health Services Research, 41(4p2), 1677-1689.

Riley, W. (2009). High reliability and implications for nurse leaders. Journal of Nursing Management, 17, 238-246.

Sherwood, G., & Barnsteiner, J. (2012). Quality and safety in nursing. A competency approach to improving outcomes. Chichester, UK: John Wiley & Sons, Inc.

Spoelstra, S.L, Given, B.A., & Given, C. W. (2012). Fall prevention in hospitals: An integrative review. Clinical Nursing Research. 21(1), 92-112.  

Weick, K. E., & Sutcliffe, K. M. (2001). Managing the unexpected: Assuring high performance in an age of complexity (1st ed.). San Francisco, CA: Jossey-Bass.

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in and age of uncertainty. (2nd Ed.) San Francisco, CA: Jossey-Bass.

White, S. V. (2012). Quality and performance improvement in Q. Solutions. (3rd Ed.) Glenview, IL: NAHQ.

Wu, S., Keeler, E., Rubenstein, L., Maglione, M.A., & Shekelle, P.G. (2010). A cost-effectiveness analysis of a proposed national falls prevention program. Clinical Geriatric Medicine. 26. 751-766.

© 2013 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2013

Related Articles