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Designing and Implementing a Zero Harm Falls Prevention Program

A Quality Improvement Study

Wilson, Mary-Agnes PhD, RN; Hacker Teper, Matthew MSc; Sinno, Maya BSN, RN, EMBA, CPHQ, ISQua Fellowship; Kohlberger, Kim RSW, MHSM; Nuseir, Deema MSc, BA, CPHQ; Chan, Angela MN, RN, GNC(C); Palomera-Dinglasan, Kristen MA; Leon, Lauren MBA; Donaldson, Dawn BN, MHM (c); Taher, Ahmed MD, MPH, FRCPC

Author Information
doi: 10.1097/NCQ.0000000000000617


The prevention of falls with harm for patients continues to present challenges for hospitals globally.1–4 Patients admitted to hospitals have an increased risk of falling during their inpatient stays.2,4,5 Falls are the leading cause of preventable injury during hospital admissions4 and may lead to decreased mobility, functioning, and participation in daily activities.6,7 Falls may also contribute to prolonged hospital stays6,7 and higher mortality.6–9 They may result in anxiety, depression, and decreased quality of life for patients.2,10,11 Moreover, falls are associated with increased financial costs to patients, families, and the health care system.5,6,12–16 For example, the estimated annual cost of serious episodes of injuries from hospital falls in the United States is $50 billion.3

Given the physical, mental, and financial impacts of falls on patients and the health care system, a multitude of prevention strategies have been trialed.1–4,10 These strategies address biological, behavioral, environmental, and socioeconomic risk factors for falls.1–4,10,17–19 Examples of effective strategies include risk identification and targeted interventions, exercise programs, interprofessional management of patients with hip fractures, multicomponent delirium prevention in hospitalized older people, and patient/family engagement in falls prevention strategies.1,4

While the falls prevention programs described have led to reductions in injurious falls,4 the prevalence of these preventable adverse outcomes remains high across inpatient settings. As the average age of the global population rises, the incidence of falls is expected to dramatically increase.1,8 Finally, the emergence of the COVID-19 pandemic has challenged hospital systems to prioritize infection control policies that may limit the effectiveness of traditional patient safety and falls prevention initiatives.20–22

Given this persistent propensity for inpatients to fall, the limited effectiveness of isolated falls prevention strategies, and an elevated rate of falls in 2019, Mackenzie Health (MH) implemented a zero harm23 approach to preventing falls. Specifically, MH aimed to have zero falls with injury in all inpatient and ambulatory populations by April 2023. The year 1 objective was to reduce the number of inpatient falls with injury by 25% by April 2021. The purpose of this article is to provide an overview of the design, implementation, and evaluation of the MH falls prevention program.



MH is a regional health system serving a population of more than half a million people within and beyond Toronto, Canada. In 2019, MH comprised more than 600 beds. Its inpatient capacity is divided between 271 acute care beds including medical, intensive care, surgical, mental health, pediatric, and obstetrical care. MH also has 96 complex continuing care/rehabilitation beds, 168 long-term care beds, and 112 Reactivation Care Centre beds. At the beginning of its falls prevention initiative in April 2020, MH had been averaging a fall with injury incidence rate of 2.03 per 1000 patient-days over a baseline period of 6 months.


Implementation of the zero harm falls quality aim was guided by a standardized process in collaboration with the MH Office of Strategy Management. The aim was first conceived in February 2020, with the stroke program director selected to lead it, given their prior experience in championing a successful unit-level, evidence-based falls prevention program. An interprofessional falls quality aim committee, consisting of direct care nurses, nurse educators, physiotherapists, occupational therapists, physicians, clinical managers, quality improvement (QI) specialists, and patient partners, was also established to have oversight and drive the improvement efforts of this organization-wide strategy. This QI study was granted ethics exception by the Southlake Regional Health Center Research Ethics Board (SRHC REB). Implementation and study of this intervention were completed without funding support.

Development and dissemination of change factors and change ideas

In March 2020, the falls quality aim committee developed a project charter outlining the scope and initiatives of the quality aim. The specific change factors (drivers) and change ideas selected for year 1 interventions are described in the Table. These change ideas were prioritized on the basis of perceived impact and feasibility of achievement within the year. Additional change ideas to be implemented in subsequent iterations of the program are listed in the Supplemental Digital Content, Table 1 (available at: A lead was assigned to each change idea. Inpatient unit managers also received communications about the program aims to provide unit-level education and to remind frontline staff of the existing falls prevention policy and falls risk assessment and mitigation strategies. Direct care staff were empowered to share feedback on barriers and opportunities for improvement in the existing strategies. Finally, the organization-wide zero harm journey was launched and disseminated through visual communication posted in various areas across the hospital starting April 2020.

Table. - Summary of Change Factors (Drivers) and Change Ideas Implemented in Year 1 of the Zero Harm Falls Initiative
Change Factors (Drivers) Change Ideas
Falls quality aim committee Establish a collaborative committee to provide organization-wide falls oversight
Program and unit accountability Establish accountability for leaders at all levels (organization-wide)
Access to data Conduct current state gap analysis on falls data collection and validity
Align the EMR and safety reporting system
Implement an electronic dashboard with real-time unit-specific falls data
Reporting Implement a process to ensure all falls and near misses are reported
Audit compliance with high-risk assessment and generate unit-specific reports
Screening for high-risk and vulnerable populations Identify the validated falls risk assessment tool for implementation
Establish the EMR process for assessment tool utilization and assessments triggered base on results
Implement the screening tool across inpatient programs
Mitigation strategies Conduct current state gap analysis on falls intervention strategies (organization-wide)
Interdisciplinary communications Develop and implement the standardized tool to communicate falls risk and prevention strategies to the interprofessional team, including alerts for patients with repeat falls
Safe environment Review and reinforce regular environmental audits to ensure adherence to falls prevention interventions
Evaluate adherence to plan Establish mechanisms to promote and monitor intervention adherence
Patient and family engagement Engage patients and their families in individualized falls prevention strategies
Abbreviation: EMR, electronic medical record.

Implementation of electronic dashboards and the Morse Fall Risk Assessment tool

In July 2020, unit-level electronic dashboards were implemented to give more proximal feedback to units on their falls prevention performance. Dashboards were updated in real time and reflected each unit's falls rate per 1000 patient-days, relative to a target falls rate that was established by the falls quality aim committee. These dashboards were installed across hospital units, and direct care staff were encouraged to review their unit's performance at routine team huddles. Next, after a successful pilot period between August and November 2020, the Morse Fall Risk Assessment tool24 was integrated into the electronic medical record (EMR) system. The Morse Fall Risk Assessment tool was selected for its ease of use and the ability to benchmark with other health sectors. The 6-item tool was tested and evaluated by 42 direct care nurses, with feedback, which was incorporated into the final build. During this time, direct care staff were provided extensive education on how to use the tool. A hospital-wide rollout of the Morse Fall Risk Assessment tool was established in December 2020.

Employment of evidence-based falls-reduction interventions

In addition to these practices, a series of evidence-based interventions designed to reduce the rate of inpatient falls were implemented. These included enhancing interdisciplinary communication using alerts, employing standardized tools to communicate falls risk and falls prevention strategies between providers, increasing the safety of toileting and mobility, monitoring patient medications, and soliciting staff feedback on barriers to falls prevention. Patient and family engagement was increased by including patients and family members in post-fall huddles. Furthermore, to prevent falls postdischarge, patients were offered a predischarge home visit and risk assessment by an occupational therapist and access to in-home exercise programs.

Customizing an electronic reporting system and safety review process

To improve the safety culture, MH aimed to create a psychologically safe environment for reporting safety events, including near misses and capturing patients with repeat falls. Falls with injury were captured through an electronic reporting system where the direct care staff involved filled out events in real time. A novel 3-step safety review process for reporting incidents including falls and falls with injury was launched. This included a review for quality, risk, impacted clinical area(s), and physicians involved. Following each review, a root-cause analysis of contributing factors and system vulnerabilities was performed. This transparent systems-level process further supported the safe space for staff to report and further prevent falls on their units. Finally, data collection was through direct observation and medical record reviews were intermittently completed to ensure accurate and timely reporting of events through the safety reporting system.


Design, implementation, interpretation, and reporting of the intervention were guided by the SQUIRE 2.0 guidelines.25 The primary outcome measure for this project was the number of falls with injury per 1000 patient-days. The target was to reduce the falls with injury rate below 1.52 (25%) per 1000 patient-days in the first year. The process measure was change in patient safety incident reporting.

Data analysis

Data were analyzed via Statistical Process Control ([SPC] or Shewhart) XbarR charts to assess for special cause variation. SPC charts were completed with QI Macros (version 2018.04; KnowWare International Inc, Denver, Colorado) for Microsoft Excel (version 14.5.9; Microsoft Corporation, Redmond, Washington).


Since the implementation of this multifaceted and multidisciplinary falls prevention strategy in April 2020, the incidence of patient falls with injury has reduced over time. Figure 1 shows the 6-month baseline period between October 2019 and March 2020, having an average rate of 2.03 per 1000 patient-days. All 3 major interventions of the program launch (April 2020), electronic dashboards (July 2020), and Morse tool adoption (December 2020) showed process changes on the SPC chart. The average number of falls with injury progressively decreased throughout the intervention period, culminating in a rate 1 year later in April 2021 of 1.12 falls per 1000 patient-days and an average of the last 6 months of the intervention period of 1.02 falls per 1000 patient-days. No special cause variation was noted.

Figure 1.:
Falls and injury per 1000 patient-days at Mackenzie Health.

The process measure also reflected an increase in patient safety incident reporting. Despite the decrease in falls with injury, patient safety reporting nearly doubled in frequency between April 2020 (n = 110) and March 2021 (n = 216). This is depicted in Figure 2.

Figure 2.:
Mackenzie Health patient safety event reporting.

Changes in falls rates manifested differently across clinical areas, severity, contributing factors, and patient demographics. For example, of the falls that continued to occur after the intervention was implemented, proportionally fewer (43.8%) occurred on medicine wards than before the intervention (54.9%). Falls after the intervention were also more likely to be assessed as mild (92.6% before, 96.1% after). There were no notable changes in the prevalence of factors that contributed to falls (eg, toileting, medication-induced, footwear). After the intervention, there were proportionally fewer falls among those who were older than 80 years but there was a greater proportion of falls in those patients aged 60 to 79 years. A complete comparison of changes in falls prevalence is provided in Supplemental Digital Content, Table 2 (available at:

In addition to the reduction in the falls rate, the clinical staff demonstrated increased awareness around falls prevention and increased use of real-time falls rates displayed on the unit dashboards daily. Teams regularly engaged in open discussions around current falls prevention strategies and potential changes needed. This led to a resurgence of the importance of falls prevention across the organization.


This article reports on the design, implementation, and preliminary evaluation of a multifaceted approach to preventing unnecessary falls with injury for patients admitted to the MH hospital system. By taking an organizational, interprofessional, and collaborative approach, MH has been able to decrease its falls with injury rate from a baseline of 2.03 to 1.12 per 1000 patient-days.

Beyond reducing patient injuries from falling, the commitment to diverse stakeholder engagement, solicitation of feedback, and incorporation of needed changes to the falls prevention workflow has led to a perceptible increase in patient safety culture and commitment. This mutually reinforcing relationship between decreasing a serious safety event rate and increasing patient safety culture has been described elsewhere23 and is viewed as a major benefit of the zero harm approach. While the MH journey toward a complete elimination of injuries from falls is just beginning, these preliminary findings support the zero harm philosophy that, when hospital systems invest in multifaceted approaches to reducing harm, a substantial proportion of adverse events to patients can be prevented.26,27

Of all the change ideas implemented in the first year, 2 initiatives appear to have been especially impactful on the organization's ability to prevent unnecessary patient falls. First, the unit-level quality dashboards were praised for their ability to make falls data accessible to direct care nursing and other staff members and to instill an increased sense of accountability for staff regarding their unit-specific falls rates. Much of this dashboard's success was predicated on it integrating into current processes without increasing staff workload. Similarly, it was important that the falls reporting system be easy to access and use such that it minimized barriers to staff reporting falls and near misses. The marked increase in patient safety incident reporting throughout the year (the process measure) supports the notion that the decrease in falls observed is due to improvements in culture and practice, not a reflection of decreased reporting.

A second important intervention was the implementation of the Morse Fall Risk Assessment tool. By applying an easy-to-use, organizational standard to evaluating patient falls risk at the time of admission, nursing and other staff members were able to treat patients and mobilize resources accordingly to mitigate falls risks. While these initiatives have, individually, been implemented at other institutions to reduce the rate of inpatient falls, we believe that the combination of these 2 interventions, coupled with more standard falls prevention practices, was key to initiating and sustaining the decrease in inpatient falls rate throughout the year.

While MH was eventually able to achieve its target reduction in falls rate, the approach implemented was not without challenges. For example, despite an initial improvement in falls with injury rate upon program launch in April 2020, there was an increase in patient falls with injury in the 3 months that followed. This transient return to baseline in patient falls may be attributed to the gradual rollout of the zero harm falls prevention program. For example, electronic dashboards were not unveiled until July 2020, and the full risk assessment tool integration with the EMR system did not occur until December 2020. This lack of early success of the program suggests that QI—especially on the scale of multiple hospital units—is accomplished on the time frame of months and years, not days and weeks.28,29 In the case of MH, it appears that sustainable change in patient safety occurred through a combination of researching best practices, reforming current policy, engaging direct care and administrative stakeholders, building a safe space for program feedback and revision, integrating new technologies in ways that aligned with current workflows, and advertising heavily.

The necessity of a multifaceted approach may be reflective of the multidimensional nature of patient safety culture30,31 and is consistent with previous falls prevention literature that suggests that single interventions alone (eg, signage, medication review, urinalysis, routine prescriptions of vitamin D) are generally not successful in reducing falls or their sequelae.31,32 The temporary falls injury rate improvement in April 2020 also raises the possibility that data collected may have initially been temporarily influenced by the Hawthorne effect—where the clinical staff observed only temporarily changed falls prevention behaviors because they were aware they were under study.33


This article reports only on the first year of a zero harm program. While the targets carry onto the future, our current ability to make inferences on the long-term sustainability of the program is limited. The generalizability of these findings may be limited because of the exceptional nature of the COVID-19 pandemic, which has changed the nature of patient care in unique ways. Despite these limitations, this study is strengthened by a clear description of the setting and implementation of the zero harm approach and by a contextualization of changes in rates of falls with injury with key implementation steps of the falls prevention program.


This study details a novel zero harm falls prevention program, developed at an urban regional health system. It demonstrates a gradual but sustained decrease in injuries from falls between April 2020 and July 2021. Next steps include continuing to monitor the effect of the year 1 program elements while introducing new change ideas as MH continues its pursuit of eliminating harm from patient falls by 2023.


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accidental falls; falls prevention; interdisciplinary communication; patient safety; quality improvement

Supplemental Digital Content

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