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Implementing a pediatric fall prevention policy and program.

Patient safety in the hospital setting is a priority in healthcare. The Joint Commission and The Health and Medicine Division have placed great emphasis on patient safety and decreasing adverse events during hospitalization (Rouse, Close, Prante, & Boyd, 2014). One of the National Patient Safety Goals outlined by The Joint Commission is to reduce the risk of harm to patients caused from falls. Individuals in the hospital setting are at a greater risk for falls related to physiological factors, medications, and the use of equipment (Rouse et al., 2014). This increased risk applies even to the pediatric population, where fall rates range from 0.56 to 2.19 falls per 1,000 hospital days (Pauley, Houston, Cheng, & Johnston, 2014). Failure to provide a safe environment can lead to falls that may possibly result in injury. These injuries have the potential to increase the duration of a patient's hospital stay, increase the risk of complications, and decrease the trust families have in their healthcare provider (Graf, 2011). To address this risk, in 2006, The Joint Commission required hospitals to implement fall prevention programs and evaluate the effectiveness of such programs (Pauley et al., 2014).

With pediatric patients at a high risk for injury due to falls, The Joint Commission recommends each hospital have a method of identifying and screening children at risk (Rouse et al., 2014). Preventing patient falls begins with an accurate assessment of a patient's risk of falling followed by the initiation and continued evaluation of a fall prevention program based on patient-specific identified risks (Graf, 2011). Prevention programs that have revealed the most favorable results include the use of a validated fall risk assessment tool. The use of such a tool provides direction for care plan protocols and utilizes fall classification data to implement population-based interventions (Graf, 2011). Many risk assessment tools are available; however, most are intended for adults and not specifically designed for the pediatric population (Rouse et al., 2014).

Background and Significance

Children have a normal tendency to fall based on developmental growth (Kramlich & Dende, 2016). However, children with medical conditions, such as neurological issues, may be at greater risk for falling (Harvey, Kramlich, Chapman, Parker, & Blades, 2010). Each child is different in physical and cognitive abilities. As children grow and develop, they approach mobility in different ways; infants crawl, toddlers stumble with unsteady gait, pre-school children climb and hang, school-age children must be told to walk and not run, and adolescents can be daredevils (Kramlich & Dende, 2016). Although falls may occur both in and out of the hospital setting, a hospitalized child's medical condition, treatments, and medications can further compromise normal developmental and prospective control, placing them at an increased risk for falls.

Pediatric patient falls are categorized as physical, physiologically anticipated, physiologically unanticipated, response to treatment, developmental, roughhousing, or accidental (Ryan-Wenger & Dufek, 2013). Prevention of falls in the hospitalized pediatric patient population is an important aspect of care. Both healthcare providers and parents should understand that hospitalized children are at an increased risk for falls related to a new environment, impaired gait, and possible disorientation related to illness (Razmus, Wilson, Smith, & Newman, 2006). Pediatric nurses who provide direct patient care are vital in protecting patients from falls and are generally those who report falls (Kramlich & Dende, 2016). The possibility of underreporting by staff is a cause for concern because falling can be normal in the pediatric population related to age and developmental growth (Pauley et al., 2014). To address this problem, a valid and reliable tool for screening for fall risk in the pediatric population is necessary.

Currently, there are several pediatric screening assessment tools, such as General Risk Assessment for. Pediatric Inpatient Falls (Graf-PIF), CHAMPS, Cummings scale, Children's National Medical Center (CNMC) scale, and the Humpty Dumpty Fall Scale (Kramlich & Dende, 2016). For this project, the Humpty Dumpty Fall Scale screening tool was used to increase awareness of patients who are at risk for falls and to decrease the rate of falls of pediatric patients in the hospital setting. The Humpty Dumpty Fall Scale is specifically developed for pediatric patients to assess risk for fall. The tool is broken down into categories consisting of age, sex, diagnosis, cognitive impairments, environmental factors, response to surgery/anesthesia/sedation, and medication usage. Based on scores, pediatric patients are placed into two categories, either low risk (< 12) or high risk (> 12) (Rouse et al., 2014).

Evidence Review and Literature

A review of the evidence revealed an abundance of literature regarding falls in the adult population; however, literature on falls in the pediatric population is scarce. The following articles were selected for review based on literature limited to fall events in hospitalized children.

Cooper and Nolt (2007) found that despite general assumptions that falls for children were normal, falls are not accidental and are often consequences of specific intrinsic factors, such as age, growth and development, vision, gait, and medical condition. These researchers implemented a pediatric fall prevention program that assessed patients on admission, during shift assessment, upon transfer, change of condition, post-procedure, or post-fall. The program was implemented and supported with staff education tools, and presented at a staff meeting. Education was provided with literature, and staff were provided information outlining fall risk and prevention interventions. Challenges with implementing a hospital-wide program included consistent and timely manner of executing the new program as planned and realizing that some departments required further education. To help address these challenges, an Internet-based mandatory education component was developed, as well as the identification of champions for each unit who would continue to analyze data to evaluate effectiveness (Cooper & Nolt, 2007).

Rouse and colleagues (2014) looked at the implementation of the Humpty Dumpty Fall Scale as a quality improvement (QI) project for the emergency departments, birth centers, NICUs, and pediatric units at Palomar Pomerado Health. Prior to implementing the program, they reviewed information regarding pediatric falls and found there had been no falls reported. The authors assumed there were several unreported falls due to underreporting. After education of staff was completed and the program was implemented, feedback indicated that the Humpty Dumpty Fall Scale tool was helpful for screening in clinical practice and heightened awareness about patients who were at risk for falling (Rouse et al., 2014).

In another study, Harvey et al. (2010) completed an evaluation of five pediatric falls assessment tools. The five instruments evaluated were Graf-PIF, CHAMPS, Humpty Dumpty Fall Scale, Cummings scale, and the CNMC scale. These researchers determined that two instruments performed well in identifying those at risk for falls. Findings during the study indicated that the Humpty Dumpty Fall Scale had the highest specificity (80%). The Humpty Dumpty Fall Scale was the only instrument to correctly identify all of those at high risk for falls within the sample and was the only instrument to identify the very high-risk fallers (Harvey et al., 2010).

Hill-Rodriguez et al. (2009) assessed whether the Humpty Dumpty Fall Scale could be used to identify inpatient pediatric patients at risk for falls and found that the Humpty Dumpty Fall Scale is a valid tool for identifying those patients. Results indicated that high-risk patients fell almost twice as often as low-risk patients. Hill-Rodriguez et al. (2009) found that using the Humpty Dumpty Fall Scale on admission, during each shift, and with any change in the patient's status could increase staff awareness of patients who were at high risk for falls. Findings also suggested that the use of the Humpty Dumpty Fall Scale score gave the healthcare provider a point of reference when accessing pediatric patients at-risk for falls (Hill-Rodriguez et. al 2009).

Overall, evidence strongly suggests that implementation of a pediatric fall prevention program using an effective tool such as the Humpty Dumpty Fall Scale can increase healthcare provider awareness of those at risk for falls and reduce the rate of falls for the inpatient pediatric population (Cooper & Nolt, 2007; Harvey et al., 2010; Hill-Rodriguez et al., 2009; Rouse et al, 2014).


The fall rate per 1,000 patient days at the facility where the pediatric fall prevention project was implemented was 3.16% for 2015, which is above the average for fall rates in the pediatric population, which ranges from 0.56 to 2.19 (Pauley et al., 2014). The fall rate for January to June was 4.5% per 1,000 patient days. An informal survey of each pediatric staff member revealed that staff currently under-reported falls. Most staff only reported a fall if there was visible injury, and many felt no need to report a fall because it was considered normal for that child's developmental stage. There were also several staff members who were unclear of what comprised the definition of a fall. After examining the fall data and discussing the topic of falls with the staff, the need for an inpatient pediatric fall prevention program and policy was identified.

The purpose of this project was to implement a pediatric fall prevention program and policy on an inpatient pediatric unit with a goal to decrease pediatric falls. The specific clinical question asked was, "Will increasing staff awareness of pediatric patients at risk for falls through the implementation of an evidence-based pediatric fall prevention program and policy decrease the rate of falls for the inpatient pediatric population?"


Theoretical Framework

The Plan-Do-Study-Act (PDSA) cycle served as a framework for this project. The PDSA cycle is a widely accepted and effective method for testing and learning about change on a small scale. When using the PDSA cycle, a specific change is planned and implemented, the results are observed, and action is taken on what is learned (Melnyk & Fineout-Overholt, 2011).

Setting and Sample

The project was conducted on a six-bed pediatric and pediatric intensive care unit staffed only by registered nurses (RNs) in a mid-size hospital in the southeastern United States. The project included all patients, newborn to 18 years of age, admitted to the six-bed pediatric unit, including both general pediatric patients and pediatric intensive care patients.

Project Design

This QI project had multiple initial components that involved evaluating the problem of falls. This included existing fall risk data at the project site and the development of a policy and subsequent plan for fall prevention where nothing specifically designed for pediatrics was previously in place. Without a pediatric-specific policy in place at the project site and an overall fall risk of 3.16% per 1,000 days for 2015, the project coordinator created a policy for Pediatric/Pediatric Intensive Care Unit (PICU) Fall Risk Assessment and Prevention Program. The policy outlined the purpose, scope, definitions, procedure, and documentation of the prevention program. The policy was presented to and received approval from the Women's and Children's Practice Council, the Pediatric Physicians Advisory Council (PPAC), and final approval by the chief nursing officer for the facility. The policy also outlined a pediatric fall prevention program, the Humpty Dumpty Fall Scale, which was implemented on all patients admitted to the six-bed unit.

Once a policy and plan were in place, the first step was education of all RN staff on use of the Humpty Dumpty Fall Scale tool and fall prevention interventions. This included mandatory in-services to provide education for use of the Humpty Dumpty Fall Scale tool and required documentation in the electronic medical record (EMR). Each staff member had to be signed off confirming they were provided the required education and understood the information and process for the fall prevention program. A diagram was also placed within the area that nurses used when documenting that provided a step-by-step process for the fall prevention program. Guidelines stipulated that the Humpty Dumpty Fall Scale risk assessment tool was completed on admission, at least once a shift, and as needed for any change in patient status, and post-fall. When a patient was identified as a fall risk, either low risk (score of 7 to 11) or high risk (which is scored as 12 or higher), the appropriate fall prevention interventions were implemented. These interventions included family and patient education, signs placed in the patient's room and on the patient's chart identifying that patient as high risk for falls, orientation to the unit, environmental safety, patient rounding hourly (if high risk), and ensuring that high risk for falls is initiated on the patient's care plan.

Data collected for pre-intervention included the number of falls reported by an occurrence to the risk manager and the fall rate per 1,000 patient days for a six-month period in 2015. The six-month time frame was from January to June. Post-intervention data were also collected for a six-month period (January to June 2016) and included the number of falls reported by occurrence to the risk manager and the fall rate per 1,000 patient days.

Results and Discussion

There were no falls on the pediatric unit between January and June 2016, resulting in the fall rate per 1,000 patient days at 0%, compared with a 4.5% per 1,000 days for the unit between January and June 2015. The acceptance, cooperation, and support of the unit staff while implementing the fall prevention program were instrumental in the success of the program.

Although the project was successful, there were some limitations. The program and policy were not accepted hospital-wide for every area that provided care to the pediatric population. Another limitation was the size of the unit (six beds) where the project was conducted. The effectiveness of the program will continue to be evaluated to ensure that unit staff receive the necessary education to navigate the fall prevention program and that patients are being provided safe, high-quality care guided by evidence-based nursing.

Implications for Nursing Practice And Leadership

Pediatric nurses play a pivotal role in the prevention of inpatient falls in the pediatric population. The development and implementation of a fall prevention policy and program into practice can provide the tools needed to prevent falls. The first step in developing a successful fall prevention program is acceptance and cooperation of staff. Evidence shows that a comprehensive fall prevention program that uses a valid and clinically tested screening tool, has staff support, and includes fall risk interventions in the EMR provides the best outcome to assist in identifying those at risk for falling (Kramlich & Dende, 2016). It is also necessary to provide staff with ongoing education in order to maintain a fall prevention program. Preventing falls in the inpatient pediatric population can prevent injury that can lead to prolonged hospital stay, complications, and decreased trust between the healthcare provider and patient and family (Graf, 2011). A fall prevention policy and program can increase staff and family awareness and decrease the rate of falls in the pediatric inpatient population, improving the safety and quality of patient care.

As health care organizations continue to face increasing demands to improve the quality of care, nurses from the board room to the bedside continue to play a significant role in quality improvement activities that will ultimately position organizations positively, well into the future. The establishment of the Doctor of Nursing Practice (DNP) program is one example of how the profession of nursing is examining the current and forecasting the future health care environment to inform interventions that will ultimately strengthen the profession of nursing. The DNP program involves the implementation of capstone projects that focus on improving the work environment through quality improvement methodologies. These projects involve transforming research findings into practice or applying interventions that ultimately improve patient care outcomes. If you are interested in submitting a manuscript to the Quality Improvement column, please send the appropriate material to Renee Roberts-Turner, DHA, MSN, RN, NE-BC, CPHQ at


Cooper, C., & Nolt, J. (2007). Development of an evidence-based pediatric fall prevention program. Journal of Nursing Care Quality, 22(2), 107-112.

Graf, E. (2011). Magnet children's hospitals: Leading knowledge development and quality standards for inpatient pediatric fall prevention programs. Journal of Pediatric Nursing, 26(2), 122-127.

Harvey, K., Kramlich, D., Chapman, J., Parker, J., & Blades, E. (2010). Exploring and evaluating five pediatric falls assessment instruments and injury risk indicators: An ambispective study in a tertiary care setting. Journal of Nursing Management, 18, 531-541.

Hill-Rodriguez, D., Messmer, P.R., Wiliams, P.D., Zeller, R.A., Williams, A.R., Wood, M., & Henry, M. (2009). The Humpty Dumpty Falls Scale: A case-control study. Journal for Specialists in Pediatric Nursing, 14(1), 22-32.

Kramlich, D.L., & Dende, D. (2016). Development of a pediatric fall risk and injury reduction program. Pediatric Nursing, 42(2), 77-82.

Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare (2nd ed.). Philadelphia: Wolters Kluwer & Lippincott Williams and Wilkins.

Pauley, B.J., Houston, L.S., Cheng, D., & Johnston, D.M. (2014). Clinical relevance of the Humpty Dumpty Fall Scale in a pediatric specialty hospital. Pediatric Nursing, 40, 137-142.

Razmus, I., Wilson, D., Smith, R., & Newman, E. (2006). Falls in hospitalized children. Pediatric Nursing, 32(6), 568-572.

Rouse, M.D., Close, J., Prante, C., & Boyd, S. (2014). Implementation of the Humpty Dumpty Falls Scale: A quality-improvement project. Journal of Emergency Nursing, 40(2), 181-186.

Ryan-Wenger, N.A., & Dufek, J.S. (2013). An interdisciplinary momentary confluence of events model to explain, minimize, and prevent pediatric patient falls and fall-related injuries. Journal for Specialists in Pediatric Nursing, 18(1), 4-12.

Elizabeth Murray, BSN, RN, is a DNP Student, Medical University of South Carolina College of Nursing, Charleston, SC.

Joy Vess, DNP, ACNP, BC, is an Assistant Professor, College of Nursing, Medical University of South Carolina, Charleston, SC.

Barbara J. Edlund, PhD, ANP, BC, is a Professor, College of Nursing, Medical University of South Carolina, Charleston, SC.
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Title Annotation:Quality Improvement
Author:Murray, Elizabeth; Vess, Joy; Edlund, Barbara J.
Publication:Pediatric Nursing
Date:Sep 1, 2016
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