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Standardizing Falls Reporting

Using Data From Adverse Event Reporting to Drive Quality Improvement

Gardner, Lea Anne PhD, RN; Bray, Phyllis J.; Finley, Edward BS; Sterner, Carly; Ignudo, Thomas L. III BA; Stauffer, Cherie L. RN, BSN; Kincaid, Shawn A. BA, BS; Marella, William M. MBA

doi: 10.1097/PTS.0000000000000204
Original Articles

Objective To enhance the value of the Pennsylvania Patient Safety Reporting System (PA-PSRS) falls reports by developing a falls reporting program that standardizes falls reporting and provides timely benchmarked falls rates and process measurement reports hospitals can use to identify areas of improvement in their falls program.

Methods The new PA-PSRS falls reporting program requires adherence to standardized definitions of falls to generate standardized, customizable analytic reports. An advisory committee and statewide survey guided the development of the program, data definitions, system features and functionality, and methods for stratifying reporting criteria.

Results Three real-time falls outcomes and 2 falls process reports with multiple configurable options were created. A falls dashboard was developed based on gaps in falls risk assessment processes identified in PA-PSRS falls event reports. Six months after launching the program, 41.3% of Pennsylvania hospitals enrolled. The Authority's annual survey indicated 82.9% of participating hospitals found that the new falls analytic reports were somewhat useful to very useful. Preliminary impact on the falls with harm rate has been limited, a less than 1% reduction, but the ability to identify specific organizational and patient risk factors in a timely manner provides hospitals with opportunities to target falls prevention resources more effectively.

Conclusions The PA-PSRS falls reporting program's standardized definition of falls offers new analytic reports that include falls rates with benchmarking data and a falls dashboard. The benchmarking data allow hospitals to compare themselves to peer hospitals statewide. The newly expanded PA-PSRS falls reporting program has turned an adverse event-reporting program into a quality improvement tool.

From the Pennsylvania Patient Safety Authority, Plymouth Meeting, PA.

Correspondence: Lea Anne Gardner, PhD, RN, 5200 Butler Pike, Plymouth Meeting, PA 19462 (e-mail:

The authors disclose no conflict of interest.

Source of support: Pennsylvania Patient Safety Authority.

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