A Replication Study of Fall TIPS
(Tailoring Interventions for Patient
Safety): A Patient-Centered Fall
Prevention Toolkit
he Agency for Healthcare
T Research and Quality (AHRQ,
n.d.) defined a fall as a sud-
den, unintended, uncontrolled
downward displacement of a pa-
tient’s body to the ground or other
object. This includes situations in
which a patient falls while being
assisted by another person but
excludes falls resulting from a pur-
poseful action or violent blow. The
National Quality Forum (2015)
identified five levels of injury from
falls:
• None – patient had no injuries
(no signs or symptoms)
• Minor – required application of
a dressing or ice; cleaning of a
wound; limb elevation; topical
medication; pain, bruise, or
abrasion
• Moderate – needed suturing,
application of surgical tape
strips/skin glue; splinting; mus-
cle/joint strain
• Major – required surgery, cast-
ing, traction; consultation for
neurological (basilar skull frac-
ture, small subdural hematoma)
Instructions for
CNE Contact Hours
MSN J2103
Continuing nursing education (CNE)
contact hours can be earned for
completing the evaluation associated
with this article. Instructions are available
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Deadline for submission:
February 28, 2023
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28
Susan B. Fowler
Ellen S. Reising
The Fall TIPS (Tailoring Interventions for Patient Safety) Toolkit pro-
vides individualized, patient-centered fall prevention measures. In a
study exploring the toolkit’s adoption and its impact on patient
knowledge of fall risk factors and interventions, fall rates, and injury
rates, results demonstrated increased perceived patient knowledge
of patient fall risk and related prevention strategies. An overall
decrease in fall rates over time supported use of innovative, individ-
ualized fall prevention strategies.
or internal injury (rib fracture, such as familiarizing the patient
small liver laceration); patients with the environment and having
with coagulopathy who receive the patient demonstrate call light
blood products use. The call light is maintained
• Death – resulting from injuries within the patient’s reach, as are
sustained from fall, but not from personal possessions. Sturdy hand-
physiologic events causing the rails should be present in the bath-
fall rooms, patient room, and hallway.
Fall risk is assessed on all patients The bed is in low position and bed
admitted to most facilities. The brakes are locked; the bed can be
Morse Fall Scale is used widely in raised to a comfortable height when
many healthcare settings and transferring the patient. Wheelchair
included in some risk models for wheel locks also should be used
inpatient falls (Choi et al., 2018). At when the wheelchair is stationary.A
the study institution, this scale is night light or supplemental lighting
used for risk assessment on admis- is needed. The patient care area
sion, during the dayshift assessment, should be uncluttered, with surfaces
when a change in the patient’s con- kept clean and dry. Staff should fol-
dition occurs, upon transfer to low safe patient handling practices.
another unit, and after a fall. Adult patients may be offered assis-
Standard or universal fall preven- tance with toileting every 2 hours as
tion identified by the AHRQ (2018) appropriate. If a patient is identified
includes specific interventions, as high risk for fall, a yellow wrist-
Susan B. Fowler, PhD, RN, CNRN, FAHA, is Nurse Scientist, Center for Nursing Research,
Orlando Health, Orlando, FL.
Ellen S. Reising, MSN, APRN-CNS, ACCNS-AG, RN-BC, is Clinical Nurse Specialist,
Advanced Practice Nursing & Research, Dr. P. Phillips Hospital – General Surgery Unit,
Orlando, FL.
January-February 2021 • Vol. 30/No. 1
A Replication Study of Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit

medication side effects, use of walk-

Background ing aid, intravenous-related equip-
Generalized standard interventions based on level of risk are current prac- ment, unsteady gait or walk, and
tices for fall prevention, but not individualized. Dykes and colleagues cognition issues such as forgetting
(2017) developed and tested a patient-centered, individualized approach or resistance to calling for assis-
to fall prevention using an 11 x 17-inch wall poster to engage patients/ tance. The approach consisted of a
families in fall prevention at the bedside. bed poster that included fall risk
assessment items on the left side
Aim and fall prevention interventions
Replicate the study by Dykes and coauthors (2017) on a medical teleme- on the right. The bed poster focused
try unit, exploring adoption of a patient-centered fall prevention tool on risk of harm, fall risks, and fall
and its impact on patient knowledge of fall risk factors and interventions, interventions and was hung at the
fall rates, and injury rates. bedside (see Figure 1). Dykes and
colleagues suggested a patient and
family, if possible, must be included
Method
in the steps of the fall prevention
A pre- and post-intervention design was used to compare patients’ per- process.
ceived knowledge and actual fall rates before and after implementating Following the Tailoring Interven-
the tool and processes. Thirty patients were interviewed before the study tions for Patient Safety (TIPS) inter-
and at 1-, 3-, and 6-month time points during implementation (N=120). vention used by Dykes and coau-
Number and rates of falls per 1,000 patient days were calculated. Audits thors (2017) at two facilities, patient
were completed randomly to monitor adherence to the process. knowledge of fall risk and preven-
tion based on two statements signif-
Results icantly increased (p=0.001-0.31).
Patients were more knowledgeable about falls at months 1, 3, and 6 com- The mean fall rate comparing 6
pared to pre-intervention (p=0.001-0.05). Fall rates fluctuated over the 6- months of data before and after
month study, with overall reduction from 3.3% (pre-) to 1.9% (post-). intervention decreased from 3.28 to
Staff was 85% adherent with use of the laminated poster, with adherence 2.8; fall injury rates decreased from
increasing over time. 1.00 to 0.54. Positive results subse-
quently have been replicated at
Limitations and Implications other hospitals in the Partners
HealthCare system and communi-
Findings are limited to one hospital and one medical telemetry unit. cated through a formalized Fall TIPS
Results support the potential for a best practice change. Plans are to dis- Collaborative (Dykes et al., 2019).
seminate this new process to other patient units. The website for the Collaborative
(www.falltips.org) provides the
Conclusion toolkit, webinars, and implementa-
Replication in patient units outside the medical telemetry arena is suggested. tion materials.
Because this study’s focus was to
replicate previously published re-
search, a comprehensive literature
band imprinted with Fall Risk is determine the suitability of a review on fall prevention was not
placed on the patient. patient-centered fall prevention conducted. A search was conducted
For the period September 2016- tool and its impact on patient in CINAHL for 2017-2020, focusing
August 2017, 36 patient falls oc- knowledge of fall risk factors and on fall prevention, hospital (set-
curred in the study unit. Three falls prevention interventions, overall ting), and systematic reviews. Ten
occurred on average each month fall rates, and falls with injury. A articles were found but most
(range one to six). Despite use of secondary objective was to evaluate focused on fall prevention after hos-
standard high-risk fall prevention ease of use of the patient-centered pital discharge or older adults,
strategies such as a yellow armband fall prevention tool and the need resulting in one applicable study
and non-skid socks, falls and falls for modifications. discussed below.
with injury continued. A research Avanecean and colleagues (2017)
team was formed to investigate a dif- conducted a systematic review of
ferent approach to fall prevention. Review of the Literature the effectiveness of patient-centered
Dykes and colleagues (2017) de- interventions on falls in the acute
veloped and pilot tested a patient- care setting. Five randomized con-
Purpose centered, individualized approach trolled trials were included in the
The primary purpose of this to fall prevention. Interventions narrative synthesis. Three of these
research was to replicate a pub- were tailored to individual patient studies demonstrated a reduction in
lished study (Dykes et al., 2017) to needs, including history of falls, fall rates, all using personalized care

January-February 2021 • Vol. 30/No. 1 29


Fall Risk Factor and Intervention Poster
Source: Brigham and Women’s Hospital. Used with permission.
plans and patient-centered educa-
tion. One of the three trials is the
focus of this replication study.
Recently, LeLaurin and Shorr
(2019) conducted a review of the lit-
erature on preventing falls in hospi-
talized patients and found most
publications on this topic addressed
quality improvement projects. Strat-
egies used singly or in combination
included fall risk identification,
alarms, sitters, intentional round-
ing, patient education, environ-
mental modifications, physical
restraints, and patient use of non-
slip socks. Intentional rounding
and patient education involved
interaction with the patient, but
this was limited due to cognition.
Authors suggested a need for
focused research on fall prevention
strategies.
Ethics
The Institutional Review Board
approved the study at the site with
30
FIGURE 1.
expedited status. A waiver of con-
sent documentation was granted.
Investigators provided patients with
a study information sheet explain-
ing the study and participant
involvement. No patient identifiers
were noted when patients were
asked two questions about fall risk
and prevention.
Sample Selection
The poster was used with all
patients on the medical telemetry
unit at a 237-bed community hospi-
tal over 6 months (March-August
2018). Average daily census was
approximately 30 patients during
this period. Four convenience sam-
ples of 30 patients each were chosen
for interviews before the interven-
tion and at 1 month, 3 months, and
6 months during the intervention
period (N=120). Patients had to be
alert, oriented, and English- or
Spanish-speaking to be included in
the interview process.
January-February 2021 • Vol. 30/No. 1
Design and Method
Design
The study used a pre- and post-
intervention design.
Intervention
The intervention involved use of
a risk assessment poster and inter-
vention guide, as well as nursing
action, to engage the patient and
family in discussions of fall risk and
prevention. The tool was a laminat-
ed copy of a poster (11 x 17 inches).
The poster, which was an exact
copy of the one used by Dykes and
associates (2017), was hung on the
wall opposite the patient’s bed for
visibility. It was removed easily
from the wall to be held by nurses
during discussion of fall risk and
prevention with the patient and
family. The laminated surface
allowed nurses to write and remove
notes made in nonpermanent
marker. Nurses updated the poster
A Replication Study of Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit
based on the patient’s current con-
dition (e.g., peripheral intravenous
catheter discontinued). They re-
viewed the information on the tool
with the patient at least once dur-
ing each 12-hour shift.
Patients were asked to indicate
their level of agreement with the
same two statements described by
Dykes and colleagues (2017) regard-
ing knowledge of current fall risk
and prevention: (a) I am able to
identify my risks for falling, and (b)
I know what I need to do to prevent
myself from falling. A 5-point Likert
scale was used (1=strongly disagree,
5=strongly agree). When statements
were combined, range of scores was
2-10.
Additionally, audits of documen-
tation adherence on the poster were
conducted twice weekly by mem-
bers of the study team for the first 3
months of the intervention (March-
May). Five data items were collect-
ed: room/bed number, patient
name, current date and time, iden-
tification of risk factors, and nota-
tion of fall prevention plan. All
items except the room/bed number
were used in the Dykes and coau-
thors (2017) study. In April and
May, there was a decrease in adher-
ence to use of the Fall TIPS tool;
therefore, managers then mandated
the Falls TIPS poster be completed
by 11:00 a.m. on all patients.
Clinical nurses strategized to build
completion of the Falls TIPS tool
into their workflow to meet unit
expectations.
Fall and fall injury rates were
obtained for 3-6 months before
implementing the patient-centered
fall prevention intervention. After
written permission was obtained to
use the fall risk assessment poster
and intervention guide, focused
staff education materials were
shared with all nursing staff on a
medical telemetry unit. Topics
included the benefits of integrating
an individualized fall risk assess-
ment and intervention with the
current standard or universal inter-
ventions for a comprehensive,
patient-centered fall prevention
program. Current fall rates and fall
reduction goal statements also were
reviewed with the staff. Small
January-February 2021 • Vol. 30/No. 1
groups of staff were educated at a
time, providing more one-to-one
time to review a case study. The
clinical nurse specialist (CNS) held
additional small group education
workshops over 2 weeks before
implementation for nursing staff
who needed or wanted further
training. Sessions took approxi-
mately 15 minutes and included a
case study that allowed nurses to
apply the Falls TIPS tool. Role play
was used to demonstrate nurse-
patient interactions. Team members
unable to attend workshops and
any newly hired staff were given
individual education by the CNS
using the same format. Study refer-
ence binders were available at each
nurses’ station as an immediate
resource.
Before the start of the study, a
convenience sample of 32 alert, ori-
ented patients was approached by
investigators with a study informa-
tion sheet to seek their willingness
to participate in the study. Thirty
who agreed then were asked to
respond to two Likert-style state-
ments about knowledge of fall risk
factors before intervention imple-
mentation.
Following the initial question-
naire collection period, all patients
were assessed each shift using the
current process of the Morse Fall
Scale followed by individualized
teaching to patient and family (if
present) using the patient-centered
Fall TIPS prevention tool. Investi-
gators monitored adherence to doc-
umentation on the poster using the
audit form three times a week
Monday through Friday (patient
name, date, risk factors, prevention
plan).
After the first 30-day implemen-
tation period, an additional con-
venience sample of 30 alert, orient-
ed patients was approached at 1
month, 3 months, and 6 months
with a study information sheet to
assess willingness to participate in
the study. Each sample was asked to
respond to the same two Likert-type
statements about knowledge of fall
risk factors. Data collection occur-
red over 2 weeks for each group.
Team meetings were scheduled
to evaluate project implementation:
ease of use of patient-centered fall
prevention tool, issues with use,
and needed modifications. Data
(patient knowledge and fall rates
and fall injury rates) were analyzed
3-6 months following implement-
ing the patient-centered fall risk
assessment and intervention poster.
Adherence to documentation on
the patient-centered fall risk and
intervention poster was captured
with a percentage. For example, if
three of five items were document-
ed, adherence would be 60%. An
independent t-test was used to com-
pare pre- and post-scores of patient
knowledge of falls. Fall rates and fall
injury rates were based on 1,000
patient days.
Findings
Overall adherence to documen-
tation on the fall risk assessment
and intervention poster in the study
period was 84%, with improvement
over time. Initial adherence of 45%
steadily increased to 100% at the
end of the study. In 183 of 259
observations, documentation on
the poster was 100% completed
with the five key elements of the
patient’s name, date and time, iden-
tification of risk factors, and nota-
tion of an individualized preven-
tion plan.
In general, patients perceived
they were knowledgeable about
their risk for falls and how to pre-
vent a fall throughout the study
and the lead-in period (pre-inter-
vention). The mean score for state-
ment 1 (identifying fall risk)
increased from 4.13 to 4.6 at 1
month; it remained largely un-
changed at 3 and 6 months (4.57
and 4.47, respectively). The mean
for statement 2 (how to prevent a
fall) increased from 3.97 to 4.67 at 1
month; it also remained mostly
unchanged at 3 and 6 months (4.53
and 4.7, respectively). Patients’ per-
ceived knowledge of both state-
ments significantly increased after
intervention (see Table 1).
During the first month of using
the patient-centered Falls TIPS tool
(March 2018), no falls occurred in
the study unit. The fall rate
increased during April-June 2018
31
 TABLE 1.
Comparisons of Means (t-test)

Pre (n=30 patients) Pre (n=30 patients) Pre (n=30 patients)

Compared to 1 Month Compared to 3 Months Compared to 6 Months
(n=30 patients) (n=30 patients) (n=30 patients)

Question 1 -2.16 (58) -2.00 (58) -2.27 (58)

(identify fall risk) p=0.035* p=0.05* p=0.034*
Question 2 -3.46 (58) -2.67 (58) -4.00 (58)
(knowledge of prevention) p=0.001* p=0.013* p=0.000*
Combined questions 1 & 2 -3.43 (58) -2.57 (58) -3.66 (58)
p=0.05* p=0.013* p=0.001*

*p<0.05 level of significance

but not to the rate before imple- FIGURE 2.

mentation (see Figure 2). Following Fall Rates Before, During, and Immediately After Study Period
the decision to incorporate tool
completion into daily nurse work-
Fall Rate
flow by 11:00 a.m. in June, the fall
rate decreased again in July and 7 Fall TIPS tool Mandatory completion of
August (see Figure 2). At 1 month implementation tool by 11:00 a.m. rounds
following study completion, the fall 6
5.3
rate remained low; this may be
Staff
attributed to the standardized work- 5 education. 4.4
flow process using the fall risk 3.9
assessment and intervention poster. 3.7
4
Only two falls with major injury 3.3
occurred in the 7 months before 3
study implementation. However, 2.1
1.8 2.1
one of those falls escalated in sever- 2
ity because of anticoagulant med- 1.1 1.1 1.1
ication used for venous throm- 1
boembolism prophylaxis. Through- 0
out the study period (March-August
0
2018) and 24 months afterward
Oct-17

Nov-17

Dec-17

Jan-18

Feb-18

Mar-18

Apr-18

May-18

Jun-18

Jul-18

Aug-18

(September 2018-August 2020), no Sep-1.1

falls with major injury occurred in
the study unit.
Discussion
Adherence (84%) to use of the
patient-centered Fall TIPS tool was
comparable to findings noted in the
study by Dykes and colleagues
(2017) (82% & 91%). Adherence to
documentation indicated poster use
increased through the course of the
study partially because its use
became part of the workflow for
nurses and nursing assistants.
Continuous communication about
number of falls, fall rates, and falls
with injury supports awareness and
sustained use of the patient-cen-
tered Fall TIPS tool. Huddles and
Fall Rate Linear (Fall Rate)
Gemba or other communication the baseline increase compared to
boards provide verbal and visual 1-month, 3-month, and 6-month
opportunities for communication survey periods was statistically sig-
about falls. nificant (p=0.001-0.05). This find-
Patients’ perceived ability to ing was similar to that of Dykes and
identify risk and knowledge of safe- coauthors (2017), although patients
ty actions was already high before at baseline for this study had higher
the study. Perceived identification perceived knowledge. Patients and
of risk and knowledge of fall pre- family members should be educated
vention increased slightly at each on their fall risk based on findings
timeframe (1 month, 3 months, 6 from fall risk assessments.
months), but differences were not Dykes and colleagues (2017)
statistically significant. However, identified barriers to implementa-

32 January-February 2021 • Vol. 30/No. 1

A Replication Study of Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit
tion of the Fall TIPS assessment dur-
ing their investigation. One obsta-
cle was decreased awareness or
unawareness of the new guideline
or evidence. The poster seemed to
increase awareness of falls in this
study, as evidenced by discussions
at shared governance meetings.
Additionally, it highlighted the
complexity of falls and increased
the need for a team approach
involving the patient, family, clini-
cal nurse, nursing assistant, and
nurse leaders. Fall risk and preven-
tion were reported during shift
handoff by all nursing staff.
Another barrier identified by
Dykes and associates (2017) was
decreased familiarity with the tool.
Staff in the current study lacked
familiarity with the assessment but
were educated on its use before and
throughout this research. Limited
self-efficacy also was noted by staff
who were unsure how to use the
tool or forgot how to use it.
Adherence increased over time, not
only for properly writing on the
assessment but also for using it in
conversation with patients and
families. The barrier of lack of out-
come expectations (Dyke et al.,
2017) was evident in the current
study through staff members who
thought the assessment would
decrease the number of falls.
However, the evaluation was only
one part of a fall prevention plan;
other factors have to be considered,
such as rounding and toileting.
Other simple barriers were iden-
tified to use of the laminated Fall
TIPS assessment in practice. Often
dry erase markers were not available
to staff to document on the poster.
The grade of the laminate material
is important as cheaper items make
it harder to maintain integrity of
the poster, with repeated use leav-
ing it looking dirty. Using high-
grade laminate and hanging fresh
wall posters every 6 months is sug-
gested to ensure a clean surface
between patients. Other considera-
tions were the poster’s location in
the patient room and materials to
adhere it to the wall/board. The
poster must be visible from the
patient bed; however, this was not
always possible because of existing
January-February 2021 • Vol. 30/No. 1
items on the walls, so sometimes
alternative locations (e.g., bath-
room door) were used. The hooks
also were problematic. The hooks
should allow the poster to be
removed and replaced easily when
using it for patient teaching. If not,
the hooks pull off the wall and
leave no place for the poster to
hang. This affects nurses’ ability to
adhere to the process.
Limitations
Study results are limited due to a
single patient care unit with a focus
primarily on medical patients.
Generalizability to other specialty
units is not possible. The 120
patients interviewed before and
during the study were a conven-
ience sample. It is unknown if other
patients had the same or different
perceived knowledge about falls
and prevention strategies. Although
the poster was visually available in
patients’ rooms, frequency of its use
in conversation with patients and
families is unknown.
Recommendations for
Future Research
Study of the patient-centered Fall
TIPS assessment in other patient
care areas, including critical care, is
warranted. A standardized approach
to overcome barriers before and
throughout an investigation using
the assessment should be developed
to limit variability. Future research
might include family members’
knowledge of personal fall risks and
related precautions to address fami-
ly-centered care fully. Dykes and
coauthors (2019) suggested clinical
nurses be involved in redesigning
their workflow to engage patients
and families in fall prevention using
the TIPS assessment. A study com-
paring the effectiveness of various
workflow redesigns thus may add to
understanding of best practices. As
new fall prevention strategies are
developed, they should be added to
a fall prevention program that
includes the TIPS assessment to
evaluate processes and outcomes.
Nursing Implications
The Health Research & Educ-
ational Trust (2017) has promoted
the Fall TIPS assessment through
the hospital improvement innova-
tion network as an individualized,
patient-centered fall prevention
measure. The patient-centered Fall
TIPS assessment may not be appro-
priate for every patient care unit
based on the patient population.
The poster often is used interactive-
ly with patients. Confused patients
may not understand the informa-
tion. Still, staff can use the bottom
purple area to designate patients as
impulsive, in need of a chair or bed
alarm, or choosing not to follow fall
precautions. This communicates
the patient’s need for close constant
observation when out of bed.
The assessment increased aware-
ness of falls, focusing on multifac-
eted fall prevention efforts for staff
and leaders. Outcomes associated
with a fall prevention program are
not only decreased falls. A signifi-
cant outcome might be decreased
falls with injury, as suggested by
Dykes and colleagues (2017). The
current study unit also realized this
outcome during the research peri-
od. Findings showed success and
potential for a best practice change.
Changes should be based on best
evidence, clinician expertise, and
patient preferences – the three com-
ponents of evidence-based practice
(Melynk & Fineout-Overholt, 2015).
All three factors were relevant to
this investigation. Best evidence
included evidence from research
(Dykes et al., 2019; Dykes et al.,
2017), as well as fall data. Clinician
expertise was the knowledge and
experience of clinical nurses and
nurse leaders in fall prevention and
logistics of implementing fall pre-
vention strategies. Patient prefer-
ences focused on their understand-
ing, recognition, and behaviors
associated with their fall risk and
prevention. Dissemination of study
findings to other patient care units
is being done with possible oppor-
tunities to use the tool outside the
medical-surgical unit. To date, two
additional units have adopted the
fall risk assessment poster and inter-
33
vention guide at the same institu-
tion; five other units are incorporat-
ing the poster and guide at another
facility in the system.
Conclusion
Study results demonstrated in-
creased perceived patient knowledge
of patient fall risk and related pre-
vention strategies. An overall
decrease in fall rates over time sup-
ported innovative, individualized
strategies such as a colorful poster.
Replication of a study exploring the
patient-centered TIPS Fall assess-
ment (Dykes et al., 2017) yielded
similar results. Replication should
continue in patient care areas out-
side medical telemetry settings.
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prohibited without permission.