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Saturday 12:24 CST, November 28, 2015

Standards FAQ Details


NPSG (CAMH / Hospitals)

Fall Reduction Program - NPSG - Goal 9 - 09.02.01
Updated | December 09, 2008

Definition of “fall”

Q. Is there a standard definition of a resident/patient fall or does each organization need to define it?

A. Each organization needs to define what they consider to be a patient/resident fall. (Note: state law or regulation may define this for Nursing Care Centers.)


Resources for fall reduction programs

Q. Where can I find some information on how to design a fall reduction program? What are some of the risk factors we should be looking for? What are some steps that can be taken to reduce falls/injuries?


A. Some online and published resources include:

  • The Preventing Falls Targeted Solutions Tool® (TST®) is now available. The TST is an online resource that provides a step-by-step process to assist Joint Commission accredited health care organizations in measuring performance, identifying barriers to excellent performance, and implementing the Center’s proven solutions that are customized to address specific barriers. TST® modules are also  available for improving hand hygiene, hand-off communications, and safe surgery. Accredited organizations can access the TST® and solutions free of charge on their secure Joint Commission Connect extranet. Staff at Joint Commission accredited organizations can request access via the website.

  • Sentinel Event Alert 55: Preventing falls and fall-related injuries in health care facilities

  • The National Guideline Clearinghouse (enter "fall prevention" in the search field) 

  • The Department of Veterans Affairs

  • Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 2001 May;49(5):664-72. 

  • Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD000340. DOI: 10.1002/14651858.CD000340.


Inclusion of all populations


Q. When an organization has a fall risk reduction program but it does not include all populations served, how is this scored?

A. The organization’s fall reduction program is expected to include all patient/resident care settings and populations. We don’t prescribe what the program must include but there must be something to address the risk of harm from falls for all of the organization’s settings and populations. That includes the possibility that a specific unit or population had been assessed and determined to have a minimal risk of patient/resident harm from falls and that nothing further needs to be done for that setting or population. However, if a particular setting or population was simply ignored in the organization’s program, then it would not meet the requirement.



Q. Must we consider the effect of medications on patients’ risk of falling?

A. Goal 9B requires the implementation of a fall reduction program. Consideration of a patient/resident’s medication regimen is important in most settings including certain ambulatory settings (e.g., primary care, dialysis, surgery) in which:

  • The medication regimen is known (see standard MM.01.01.01, EP 1, and NPSG.08.01.01 which require organizations to obtain a list of the patient/resident’s current medications); and, 

  • Staff is competent to consider medication effect in relation to falls.It may not be appropriate or necessary in other settings (e.g., phlebotomy, diagnostic radiology) where the above are not the case. In these settings, consideration of gait, balance, cognition, and environmental factors that may contribute to falls may be more important considerations for a fall reduction program.

It is helpful to identify some of the drugs/drug classes that are most frequently associated with increased risk of falling. Some suggested medication classifications are: hypnotics, sedatives, analgesics, psychotropics, antihypertensives, laxatives and diuretics. Please consider not only the class of drug, but the number of drugs (polypharmacy) and the potential for additive effects when they accumulate in the body that also increases risk.


Infants and children

Q. We are a pediatric hospital. Kids fall all the time. Toddlers toddle. Does this really apply to us?

A. After an intensive review of this topic with experts in the field of pediatric care, we have concluded the following:

  1. Accidentally “dropped” patients (e.g., infants) are outside the scope of this safety goal

  2. There should not be a blanket exemption for pediatrics

  3. Criteria should be developed to assist in identifying populations of children at risk for harm from falls*

  4. All children should be “screened” to determine whether they are in an “at risk” population

  5. Any child who is in an “at risk” population should be assessed and protected.
    *Razmus I, Wilson D, Smith R, Newman E. Falls in hospitalized children. Pediatr Nurs. 2006 Nov-Dec;32(6):568-72.


Time frame for fall risk assessment

Q. If our inpatient fall reduction program includes a fall risk assessment of each patient, does the assessment need to be completed on admission or can it be completed within the first 24 hours of admission?


A. The organization needs to determine the timeframe that the assessment will take place. For hospital inpatients, the maximum time frame for completing admission assessments is 24 hours.