Background

Fall and injury prevention continues to be a considerable challenge across the care continuum. In the United States, unintentional falls are the most common cause of nonfatal injuries for people older than 65 years. Up to 32 percent of community-dwelling individuals over the age of 65 fall each year, and females fall more frequently than males in this age group.^{1, 2} Fall-related injuries are the most common cause of accidental death in those over the age of 65, resulting in approximately 41 fall-related deaths per 100,000 people per year. In general, injury and mortality rates rise dramatically for both males and females across the races after the age of 85, but males older than 85 are more likely to die from a fall than females.^2–6 Unfortunately, fall-related death rates in the United States increased between 1999 and 2004, from 29 to 41 per 100,000 population.^{2, 7} Sadly, these rates are moving away from the Healthy People 2010 fall-prevention goal, which specifically seeks to reduce the number of deaths resulting from falls among those age 65 or older from the 2003 baseline of 38 per 100,000 population to no more than 34 per 100,000.⁸ Thus, falls are a growing public health problem that needs to be addressed.

The sequelae from falls are costly. Fall-related injuries account for up to 15 percent of rehospitalizations in the first month after discharge from hospital.⁹ Based on data from 2000, total annual estimated costs were between $16 billion and $19 billion for nonfatal, fall-related injuries and approximately $170 million dollars for fall-related deaths across care settings in the community.^{10, 11} Several factors have been implicated as causes of falls and injuries; to date, however, no definitive predictor profile has been identified. Although the underlying status of the individual who sustains a fall may contribute to the fall and subsequent injury, the trauma resulting from the fall itself is most often the cause of morbidity and mortality.

Over the past 20 years gerontology researchers, spearheaded by Mary Tinnetti from Yale University, have carried out a significant amount of research to address the problem of falls and injuries in the community. However, ubiquitous use of successful interventions is not yet in place in the community. As health care moves toward patient-centered care, and as a growing body of research provides guidance for widespread fall-prevention programs, fall- and fall-related-injury prevention now has the potential to be addressed across the care continuum.

Inpatient fall prevention has been an individual area of concern for nursing for almost 50 years.^{12, 13} Traditional hospital-based incident reports deem all inpatient falls to be avoidable, and therefore falls are classified as adverse events. Indeed, falls are the most frequently reported adverse events in the adult inpatient setting. But underreporting of fall events is possible, so injury reporting is likely a more consistent quality measure over time and organizations should consider judging the effects of interventions based on injury rates, not only fall rates. Inpatient fall rates range from 1.7 to 25 falls per 1,000 patient days, depending on the care area, with geropsychiatric patients having the highest risk.^14–18 Extrapolated hospital fall statistics indicate that the overall risk of a patient falling in the acute care setting is approximately 1.9 to 3 percent of all hospitalizations.^16–18 In the United States, there are approximately 37 million hospitalizations each year;¹⁹ therefore, the resultant number of falls in hospitals could reach more than 1 million per year.

Injuries are reported to occur in approximately 6 to 44 percent of acute inpatient falls.^{5, 20–23} Serious injuries from falls, such as head injuries or fractures, occur less frequently, 2 to 8 percent, but result in approximately 90,000 serious injuries across the United States each year.²⁰ Fall-related deaths in the inpatient environment are a relatively rare occurrence. Although less than 1 percent of inpatient falls result in death, this translates to approximately 11,000 fatal falls in the hospital environment per year nationwide. Since falls are considered preventable, fatal fall-related injuries should never occur while a patient is under hospital care.

In the long-term care setting, 29 percent to 55 percent of residents are reported to fall during their stay.^{24, 25} In this group, injury rates are reported to be up to 20 percent, twice that of community-dwelling elderly. The increase in injury rates is likely because long-term care residents are more vulnerable than those who can function in the community.²⁶ Rubenstein²⁷ reported 1,800 long-term care fatal falls in the United States during1988. The current number of long-term care fatal falls has not been estimated; however, there are 16,000 nursing homes in the United States caring for 1.5 million residents in 2004.²⁸ This population will likely grow in the coming years, thus fall and injury prevention remains of utmost concern.

Fall and Fall-Related Injury Reporting

Falls and related injuries have consistently been associated with the quality of nursing care in the acute care setting. They are included as a nursing-quality indicator monitored by the American Nurses Association, National Database of Nursing Quality Indicators (ANA–NDNQI) and by the National Quality Forum.^{29, 30} Participation in the ANA–NDNQI provides hospitals with the ability to view their fall and injury rates in relation to other hospitals of similar type and size. However, participation in ANA–NDNQI is voluntary; despite a rapidly growing participation rate, it is not yet ubiquitous (1,089 hospitals as of June 2007, approximately 15 percent of U.S. hospitals). The National Quality Forum also advocates for voluntary reporting of quality indicators for acute care (falls prevalence and fall-related injuries) and ambulatory care (fall-risk screening for geriatrics).^{31, 32}

The Maryland Quality Indicator Project is a second voluntary national repository that provides fall and fall-related injury benchmarks for the behavioral health, long-term care, and home care settings.³³ Unfortunately, this project has a participation level of approximately 1,000 hospitals (approximately 14 percent), making national benchmarking difficult. In the home care setting, the Centers for Medicare & Medicaid Service’s Outcome and Assessment Information Set (CMS–OASIS) provides the reporting basis for the patients’ physical functioning.³⁴ Growing efforts to expand patient safety initiatives to the home care setting seek to include falls as a quality indicator for patients who are cared for at home, but who are not completely bed bound.^{35, 36} Collection of these data has the potential for organizations to track fall rates of vulnerable patients and to identify patients at risk for falls and injuries. However, further research is required to validate such screening and to examine which interventions are effective based on risk status.

In the nursing home setting, the long-term care minimum dataset (LTCMDS) is used for reporting all aspects of care. The LTCMDS captures fall and injury histories via assessments that are performed on admission and at regular intervals during a resident’s stay.³⁷ In addition, residents are evaluated for balance and for the ability to perform activities of daily living (ADLs), with the goal to apply fall-prevention measures should the patient be deficient in these areas. Recent research by Hill-Westmoreland and Gruber-Baldini³⁸ indicated only a 75 percent concordance between chart abstraction and minimum dataset reporting for a group of long-term care facilities. A more recent development in the long-term care setting, the Nursing Home Quality Initiative, promotes the collection of a list of enhanced quality indicators, including those that track declines in functional and cognitive status.^{34, 37} The Agency for Healthcare Research and Quality (AHRQ) has elected to monitor only postoperative hip fracture as their fall-related preventive quality indicator, which is consistent with thinking that monitoring fall-related injuries is a more dependable measure of quality.^{39, 40} However, tracking of all fractures would be of benefit. The Health Plan Employer Data and Information Set has recently added Fall Risk Assessment to its dataset, which will provide a method to benchmark the evaluation of fall risk between health insurance providers.⁴¹ However, application of fall- and injury-prevention programs is not included as an indicator, which will make it difficult to benchmark these important measures. Increased and more accurate monitoring of these elements has the potential to reduce falls among nursing home residents; however, the effect of these efforts has yet to be established.

Research Evidence

Falls and Related Injuries in the Community

In the following section, research about falls and related injuries in the community were identified and categorized as follows: risk factor identification, risk assessment instruments, and prevention strategies.

Risk factors in the community

The pivotal research of Tinetti, Speechly and Ginter⁴⁴ related to fall and injury prevention in community-dwelling individuals older than 65 years identified the following risk factors for falling: (1) postural hypotension, (2) use of any benzodiazepine or sedative-hypnotics, (3) use of four or more prescription medications, (4) environmental hazards, and (5) muscular strength or range of motion impairments. Other researchers have identified additional patient or treatment risk factors: (1) comorbidities, including diabetes, diabetic foot ulcer,⁵⁵ stroke,⁵⁶ syncope,⁵⁷ anemia,^{58, 59} Alzheimer’s disease,⁶⁰ Parkinson’s disease,⁶¹ vitamin D deficiency,^{62, 63} and vitamin D deficiency in combination with low creatinine clearance;⁶⁴ (2) patient characteristics, including fallophobia (also known as “fear of falling”),^{65, 66} gait problems (e.g., weakness and impaired sensation),⁶⁷ postural hypotension, inability to get out of chair, impaired ability to perform ADLs, frailty,^68–70 inability to follow instructions,⁷¹ and inability to adapt to changing environment;⁷² and (3) other characteristics, including recent hospitalization,⁹ nonsupportive footwear (e.g., slippers),⁷³ reckless wheelchair use,⁷⁴ environmental hazards, and use of psychotropic medication.^{75, 76} Age and gender are also associated with falls and fall-related morbidity and mortality. Fall rates increase with age,⁷⁷ and in community-dwellers between 65 and 85 years of age, females are more likely to fall, but males are more likely to die from fall-related injuries than females in this group.^{1, 2}

The roles of ethnicity and race in relation to falls and injury have also been studied. Reyes-Ortiz and colleagues⁷⁸ examined risk factors for Mexican-Americans and found that in the community, the risk factors are the same as for their White counterparts. Hanlon and colleagues⁷⁹ examined predictors of falls between Caucasians and African Americans and found that African Americans were 23 percent less likely to fall than Whites (odds ratio = 0.77). Faulkner and colleagues⁸⁰ explored this difference in women and found that Caucasian women were 50 percent more likely to fall than African American women, although this was not statistically significant (relative risk = 1.50, 95% confidence interval [95% CI] = 0.90–2.49). The researchers further examined situations leading to falls and found that circumstances differed by ethnicity: Caucasian women were more likely to fall outdoors versus indoors (odds ratio = 1.6, 95% CI = 1.0–2.7) and laterally versus forward (odds ratio = 2.0, 95% CI = 1.1–3.4), but less likely to fall on the hand or wrist (odds ratio = 0.6, 95% CI = 0.3–1.0). This research suggests that activities differ between older African American women and their Caucasian counterparts and should be considered when making fall- and injury-prevention plans.

Risk factors for injury in the community

Risk factors for injury in the community are increasingly well characterized. Porthouse and her research team⁸¹ performed a comprehensive cohort study of almost 4,300 women older than 70 years and confirmed the following risk factors for various types of fall-related fractures: (1) fall in the past 12 months, (2) increasing age, (3) previous fracture, and (4) low body weight. This work also identified that smoking was not associated with fracture risk. A growing body of research is examining vitamin D deficiency as a risk factor for fracture; however, results are conflicting to date, but bear further research.^{81, 82}

Colon-Emeric and colleagues⁸³ used data from a large community epidemiologic study to identify whether historical and functional information could help to predict fracture risk. The researchers identified nine characteristics that were predictors of fracture: (1) female sex, (2) age greater than 75 years, (3) White race, (4) body mass index (BMI) of less than 22.8 kg/m², (5) history of stroke, (6) cognitive impairment, (7) one or more ADL impairments, (8) one or more Rosow-Breslau impairments (e.g., perform heavy work, walk a mile, climb stairs), and (9) antiepileptic drug use. Ohm and colleagues⁸⁴ recently identified that elderly community-dwelling individuals with traumatic head injuries were more likely to die based on the use of antiplatelet therapy (relative risk = 2.5 for those taking antiplatelet therapies; P = 0.016). A similar body of research related to chronic subdural hematomas has identified that patients on anticoagulant or antiplatelet therapy are at higher risk for chronic subdural hematoma and that many of these are first identified when a patient is evaluated after a fall.⁸⁵ Many injury risk factors are consistent with fall risk factors, accentuating the need for effective screening of elderly community-dwelling individuals. However, factors that make people more susceptible to injury, such as antiplatelet therapy, establish the need for additional safety measures for individuals at risk for injury. Table 1 lists the intrinsic and extrinsic risk factors for falls, injuries, and fall-related deaths in the community.

Table 1

Risk Factors for Falls, Injuries, and Fall-Related Deaths in the Community

Risk assessment instruments for community dwellers

Tinetti⁸⁶ developed a fall risk assessment index based on the following nine risk factors: mobility, morale, mental status, distance vision, hearing, postural blood pressure, back examination, medications, and ability to perform ADLs. This instrument has been the most widely used and tested, with a reported sensitivity of 80 percent and specificity of 74 percent.⁸⁷ Other instruments used in the community include the following (with reported sensitivities and specificities in parentheses): (1) Berg Balance Test (sensitivity = 77 percent; specificity = 86 percent), (2) Elderly Fall Screening Test (sensitivity = 93 percent; specificity = 78 percent), (3) Dynamic Gait Index (sensitivity = 85 percent; specificity = 38 percent), and (4) Timed Get Up and Go test (sensitivity = 87 percent; specificity = 87 percent).⁸⁷ Aside from the Timed Get Up and Go test, which takes less than a minute for a health care provider to administer, these instruments generally take 15 to 20 minutes to complete.⁸⁷

Lord and colleagues⁸⁸ recently evaluated the effect of an exercise-related fall-prevention program, but found that the intervention was not useful in community dwellers who were not screened for risk. The researchers concluded that screening to identify individuals at high risk for falls would be necessary for a successful fall-prevention program. Further research to identify the most accurate, yet easy-to-use risk assessment instrument would be necessary to move these efforts forward.

A recent systematic review by Scott and colleagues⁸⁹ examined fall risk assessment instruments in the community. The authors concluded that, in general, risk assessment instruments are available; however, most have been tested in only one setting. Therefore, further validation studies should be conducted on fall risk assessment instruments before any specific instrument can be recommended.

A potential time point for risk assessment is in the emergency department (ED). Several researchers have examined the effect of fall- and injury-prevention interventions applied to patients who are discharged from the ED after a noninjury or nonserious-injury fall. The overarching goal of these studies is to evaluate the ability of comprehensive risk assessment followed by targeted interventions to prevent future falls and fall-related injuries. Several studies have successfully shown that screening followed by tailored management can decrease repeat falls.^{42, 90–94} Close and colleagues⁴² found that fall rates were reduced by 61 percent and recurrent falls were reduced by 67 percent for patients who had comprehensive risk assessment after a fall, compared to individuals who received standard treatment. Davison and colleagues⁹⁰ found a 36 percent decrease in fall rates after 1 year for patients who received a multimodal intervention for fall prevention after being identified as a faller on admission to the ED. In addition, these researchers noted an increase in falls self-efficacy, which is a measure of an individual’s perception of their ability to manage situations where they are at high risk for falling – the higher self-efficacy, the more able a person is able to manage high risk situations. In a related study, Lee, Hurley, and colleagues⁹¹ conducted a randomized controlled trial to examine the impact of a personal emergency response system and found that there was no difference between treatment and control groups for self-efficacy or patient anxiety. The Lee and colleagues study is informative in that emergency contact alone was not sufficient to improve a patient’s belief in their ability to manage fall risk situations. Although no standardized instrument has yet been developed for use in the ED environment, the potential for the prevention of falls and related injuries in the community would be increased with the accurate identification of patients at risk for falls while they are in the ED.

Automated risk assessment in the community setting

To date, a limited number of computer-based, community-based fall assessment instruments have been described. By far the most complex and integrated is the Fall Risk Assessment and Management System, which was developed by the Australia Family Practice Group for use in the community by family practice physicians.⁹⁵ Fall Risk Assessment and Management System includes automated recommendations after the clinician executes a thorough patient assessment. Although this system appears promising, its efficacy has not yet been reported.

Lord, Menz, and Tiedemann⁹⁶ describe an electronic fall risk assessment instrument that provides a method to measure several risk factors, including vision, peripheral sensation, muscle force, reaction time, and postural sway. Although this instrument is thorough, it is meant for use by a physical therapist or a physician, nurse practitioner, or physician assistant for a focused fall risk assessment, rather than as a triage or screening tool. The novel aspect of this instrument is the comparison of the individual’s score to the normative scores for each of the assessments, which provides the clinician with an anchor and may facilitate improved screening over time. However, the predictive validity of this instrument has not been reported, and its use may be limited to a fall-prevention clinic.

Another electronic fall risk assessment instrument, described by Dyer and colleagues,⁹⁷ is an electronic checklist in a fall-prevention clinic. Unfortunately, the researchers concluded that the clinic itself was more successful than the instrument in identifying risk factors for falling, underscoring the reality that the implementation of an instrument without associated policy and procedure changes may have limited effect.

The presence of these automated systems indicates that there is movement toward computerized fall risk assessment. Indeed, many clinical information systems have adapted paper-based assessment instruments for use in the acute care setting. However, the efficacy of these systems has not been reported, and their effectiveness is likely to be constrained by the limits of the original instrument, the system in which they are placed, and the design team in ensuring that the automated instrument accurately reflects the original instrument.

Prevention strategies in the community

To date, several reviews conducted to examine the evidence available to support practice in this area have identified the need for multimodal, interdisciplinary prevention programs; the need for more accurate risk assessment instruments; and the need for more research related to this complex and costly problem.^{11, 98–107}

Cumming¹⁰⁰ reviewed 21 trials and concluded that exercise programs were the most promising, and reduction of antipsychotic medications should be considered. However, Cumming also concluded that none of the reviewed research studies provided a definitive prevention strategy. Chang and collaborators⁹⁹ conducted a similar review targeted at examining interventions for older adults in the community and found that multimodal assessments with targeted intervention reduced risk of falls by 37 percent, and that exercise interventions reduced fall risk by 14 percent. Hill-Westmoreland, Soeken, and Spellbring³⁸ conducted a recent meta-analysis, including a sensitivity analysis, which identified an improved effect on fall prevention in the community when individualized management was added to exercise interventions. They concluded that exercise interventions were not sufficient in and of themselves, and interventions needed to be tailored to address individual risk factors.

Researchers have explored several other individual prevention strategies, including fall prevention clinics, exercise interventions with leg strengthening (e.g., Tai Chi), vitamin D supplements, home visits for safety evaluations, cataract surgery, and cardiac pacing. Falls and balance clinics present a promising community-based solution to the problem of falls.¹⁰⁸ Perell and colleagues¹⁰⁹ found a 50 percent reduction in fall rates for patients who were screened at a clinic and who had tailored interventions applied; however, this study had no control group and the researchers did not report injury rates, so the results are tentative. Clinics such as these provide focused intervention planning for patients identified at risk for falling, but the success of such clinics is contingent upon accurate identification of high-risk patients.

Identification of recurrent fallers via comprehensive screening followed by tailored interventions has been successful at reducing recurrent falls. Screening and intervention done in the ED reduced recurrent falls by 36 percent in one study,⁹⁰ and a nurse-led intervention that provided home assessment and tailored interventions reduced recurrent falls by 38 percent in another study.¹¹⁰ Hogan and colleagues¹¹¹ also evaluated tailored interventions for patients who had had a fall within the past 3 months. They found no significant differences between the intervention and control groups in fall rates or time to first fall; however, the intervention group had a longer time between falls (P = 0.001). However, the Hogan and colleagues study limited inclusion criteria to patients older than 65 years of age who had fallen in the past 3 months, and these two factors alone are likely insufficient to determine risk. These recent studies add to early work in the PROFET study, which found a 61 percent decrease in falls for patients who were identified in the ED and who had subsequent detailed risk assessment and tailored interventions.⁴²

Exercise-related interventions are by far the most commonly studied individual community prevention strategy. Most of this research indicates that exercise is beneficial for patients, and some research demonstrates that exercise regimes that involve leg strengthening and balance training, such as Tai Chi, are most effective.^112–122 Robertson and colleagues¹²³ performed a meta-analysis of four studies that examined effects of home exercise programs. They found in the pooled effect analysis that both fall and injury rates decreased by 35 percent. Exercise in conjunction with cognitive behavioral therapy, where patients are taught how to increase self-awareness about risky situations, has demonstrated promising results, including a longer time to first fall and decreased injuries.¹²⁴ Unfortunately, this work did not demonstrate an effect on falls efficacy, fear of falling, or actual fall rates. More recently, balance training has been compared to general exercise, and results show that balance training can prevent falls in the nonfrail elderly, but not in the frail elderly.¹²⁵ Lin and colleagues¹²⁶ found that deployment of large scale Tai Chi training to the general community had mixed results. Luukinen and colleagues¹²⁷ found a decrease in fall and injury rates with a targeted exercise program when compared to usual care, but the results were statistically significant only in a group that was not homebound—suggesting that early intervention may be more effective. Further research to explore interventions for homebound community dwellers, particularly for the very old and frail, will be important.

Laboratory studies indicate that calcium and vitamin D reduce bone loss,¹²⁸ and a growing body of work is examining the ability for vitamin D supplementation to prevent fractures in individuals who are vitamin D deficient. A meta-analysis performed by Bischoff-Ferrari and team¹²⁹ revealed that larger doses of vitamin D supplementation (700–800 IU/deciliter) reduced the risk of fracture by up to 26 percent, whereas smaller doses of vitamin D (400 IU/deciliter) did not reduce fracture risk. However, research to date has been inconclusive, and larger, more recent studies have indicated that the use of vitamin D does not reduce fracture risk in the general community.¹³⁰ On the other hand, vitamin D supplementation may be integral in preventing falls themselves:¹³¹ Recently, Latham and colleagues^{132, 133} demonstrated that vitamin D intake is an individual predictor for fall reduction, primarily by improving muscle strength. Bischoff-Ferrari and colleagues¹³⁴ have also identified a reduction in fall risk for women, but not for men, using vitamin D supplementation. Although these results are promising, more research is required to identify best practice recommendations related to vitamin D deficiency screening and vitamin D supplementation or other bone-supporting medication regimes.

Other researchers are exploring the ability for osteoporosis-prevention medications to reduce fracture risk.¹³⁵ Sato and colleagues^{136, 137} reported that risedronate, an oral bisphosphonate for osteoporosis prevention, was effective at preventing fracture in older females, older males who have had a stroke, and older females with Alzheimer’s disease. A recent large study by McCloskey and colleagues¹³⁸ (N = 5579) demonstrated a 20–29 percent decrease in clinical fractures in community-dwelling females older than 75 years with and without osteoporosis who were prescribed clodronate 800 mg daily. However, this study did not find a decrease in hip fractures. Recent reports of adverse side effects of large doses of bisphosphonates, including osteonecrosis of the jaw, indicate that further research is warranted and that patients should be monitored for side effects of these drugs. Other related fall prevention efforts include home assessment for risk factors with the implementation of safety devices such as handrails, nonslip surfaces on stairs, and removal of throw rugs.^139–143 Researchers who conducted a recent randomized controlled trial found that thin-soled shoes were found to be the best type of shoe for patients, rather than running shoes, which have sticky soles.¹⁴⁴ Research addressing syncope-related falls indicate that cardiac pacing may be appropriate for individuals with syncope.¹⁴⁵

Summary of community-based research on falls and related injuries

In summary, authors of several reviews have examined the efficacy of community-based fall- and injury-prevention programs. These reviewers have indicated that individualized multimodal interventions are effective at reducing falls and related injuries in the community setting.¹⁰⁵ However, multimodal interventions are not in place across primary care areas, which hinders their potential efficacy, and the aging community would likely benefit from large-scale implementation of these proven preventive interventions. (See Evidence Tables 1 through 9 for individual study results.)

Evidence Table 1

Reviews Examining Fall-Prevention Interventions in the Community

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Source	Safety Issue Related to Clinical Practice	Design Type*	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Weigand 200193	Fall and injury prevention in the community	Literature Review	Design: Review Outcomes: Fall rates	Setting: Community Population: Emergency patients	Assessment of fallers & targeted interventions	Falls: No definitive evidence to support ED assessment followed by targeted interventions is effective for preventing falls. More research required.
Cumming 2002100	Fall and injury prevention in the community	Literature Review	Design: Review Outcomes: Fall rates	Setting: Community Population: Older adults	Multiple interventions; 21 trials reviewed	Falls: Exercise programs most promising. Reduction of antipsychotic medications should be considered. No definitive prevention strategy.
Gillespie 2003104	Fall and injury prevention in the community	Meta-analysis	Design: Systematic Review Outcomes: Fall rates	Setting: Community Population: 21,668 people	Multiple interventions; 62 trials reviewed	Falls: Multimodal, interdisciplinary prevention programs are most successful. Risk Assessment: Need more accurate risk assessment instruments.
Chang 200499	Fall and injury prevention in the community	Meta-analysis	Design: Review Outcomes: Fall rates	Setting: Community Population: Older adults	Multiple interventions; 40 trials reviewed	Falls: Multimodal assessments with targeted intervention reduced risk of falls by 37 percent, and exercise interventions reduced fall risk by 14 percent.
Hill-Westmoreland 200538	Fall and injury prevention in the community	Meta-analysis	Design: Meta-analysis Outcomes: Fall rates	Setting: Community Population: Older adults in long-term care setting	Multiple interventions; 12 studies reviewed	Falls: Decrease in fall rates when individualized management added to exercise interventions.
Stevenson 2005135	Fall and injury prevention in the community	Systematic Review	Design: Systematic review Outcomes: Fracture, vertebral and nonvertebral	Setting: Community Population: Older women at risk for fracture	Review of calcium, vitamin D, and bisphosphonates	Fractures: Calcium, with or without vitamin D, reduces fractures in patients with high risk for fracture. Calcium with vitamin D can prevent fractures in women not at risk for fractures.
Shekele 200311	Fall and injury prevention in the community	Meta-analysis	Design: Meta-analysis Outcomes: Fall and injury rates	Setting: Community Population: Medicare recipients	Mulriple interventions	Falls: Multifactorial fall prevention programs decrease fall rates

*

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 2

Studies on Community-Based Fall-Prevention Screening with Tailored Interventions (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type†	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Close 199942	Tailored interventions for falls in the community	RCT	Design: RCT Outcomes: Fall rates, repeat fall rates, hospital admissions, Barthel Score (Max 100; higher score = higher functioning)	Setting: Community Population: 397 patients ≥ 65 years who presented to an accident and emergency department with a fall	Detailed medical and occupational-therapy assessment with referral to relevant services if indicated with 1 year followup.	Falls: Decreased by 61 percent for patients who were identified in the emergency department and who had subsequent detailed risk assessment and tailored interventions (odds ratio = 0.39, 95% CI = 0.23–0.66; P = 0.0002). Recurrent falls: Decreased by 67 percent (odds ratio = 0.33, 95% CI = 0.16–0.68). Hospital admissions: Decreased by 39 percent (odds ratio = 0.61, 95% CI = 0.35–1.05). Barthel score: Decline in score with time greater in the control group (P < 0.00001).
Hogan 2001111	Tailored interventions for falls in the community	RCT	Design: Randomized controlled trial Outcomes: Fall rates, repeat fall rates, time between falls, emergency department visits, hospital admissions	Setting: Community Population: 152 patients ≥ 65 years who had fallen within the previous 3 months	In-home assessment in conjunction with the development of an individualized treatment plan, including an exercise program for those deemed likely to benefit.	Cumulative number falls: No significant differences (311 v. 241, P = 0.34) One or more falls: No significant difference (79.2 percent v. 72.0 percent, P = 0.30) Mean number of falls: 4.0 v. 3.2, P = 0.43. Repeat fall rates: No significant difference Time between falls: Longer time between falls in intervention group (P < 0.001) For multiple fallers at baseline: Intervention group less likely to fall (P = 0.046) Time between falls longer for intervention group (P < 0.001) Emergency department visits: No significant difference Hospital admissions: No significant difference
Lightbody 2002110	Tailored interventions for falls in the community	RCT	Design: RCT Outcomes: Falls, functional ability, emergency department visits, admission to hospital	Setting: Community Population: 348 consecutive patients ≥ 65 years who were discharged from emergency room after sustaining a fall	Home assessment for medication, ECG, blood pressure, cognition, visual acuity, hearing, vestibular dysfunction, balance, mobility, feet and footwear	Recurrent Falls: Reduced by 38 percent Falls: Decreased falls in intervention group, but not statistically significant. Admissions and bed days: Fewer fall-related admissions and bed days in intervention group (8 and 69, respectively) than the control group (10 and 233, respectively).
Nikolaus 2003141	Tailored interventions for falls in the community	RCT	Design: RCT Outcomes: Number of falls, compliance with recommendations	Setting: Patients identified in university-affiliated geriatric hospital; intervention carried out in patients’ homes Population: 360 patients showing functional decline, especially in mobility, admitted to a geriatric hospital (mean age 81.5 years)	Comprehensive geriatric assessment followed by diagnostic home visit and home intervention or a comprehensive geriatric assessment with recommendatio ns	Falls: Intervention group had 31 percent fewer falls than control group (incidence rate ratio = 0.69, 95% CI = 0.51–0.97). Falls: For subgroup with ≥2 falls during previous year, there was a 37 percent decrease in falls (incident rate ratio = 0.63, 95% CI = 0.43–0.94).
Nitz 2004108	Tailored interventions for falls in the community	RCT	Design: pilot RCT Outcomes: Fall rates, balance measures	Setting: Australia; academic medical center Population: 73 adults (92 percent female) ≥ 65 yrs	Balance training sessions once a week for 10 weeks	Falls: Intervention and control groups both showed reduction in fall rates, but no differences between groups. Balance measures: Improved for intervention group.
Davison 200590	Tailored interventions for falls in the community	RCT	Design: RCT Outcomes: Fall rates, number of fall-related admissions, LOS, balance	Setting: Accident & emergency departments in a teaching hospital and associated general hospital in the United Kingdom Population: 313 cognitively intact patients ≥ 65 years with fall or fall-related injury and at least one additional fall in preceding year	Multimodal postfall assessment, including medical, physiotherapy, and occupational therapy evaluation	Falls: 36 percent fewer falls in the intervention group (relative risk = 0.64, 95% CI = 0.46–0.90). Proportion of fallers: 65 percent of subjects in the intervention group continued to fall compared with 68 percent in the control group (relative risk = 0.95, 95% CI = 0.81–1.12). Hospital admissions: Number of fall-related visits and hospital admissions was not different between groups. Hospitalization: Duration of hospital admission was reduced (mean difference admission 3.6 days, 95% CI = 0.1–7.6). Activities-specific balance confidence score: Improved in the intervention group.
Perell 2006109	Tailored interventions for falls in the community	Pretest post-test design	Design: Pretest, post-test Outcomes: Falls, repeat falls	Setting: Urban Los Angeles – Veterans Affairs System Population: 120 elders referred to the clinic. Gender not reported.	Screening following by tailored interventions at falls clinic	Falls: Reduction of total falls (pre = 297; post = 141; P = 0.0002). Increase in falls reported by 12.5 percent patients. Mean fall rates: Reduction in mean falls (pre = 4.1;post = 2.0). Repeat falls: Reduction in repeat falls (pre = 86 percent; post = 51 percent).

†

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 3

Studies Examining Exercise-Related Interventions in the Community (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type‡	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Reinsch 1992124	Exercise-related interventions for fall prevention in the community	RCT	Design: Four-arm RCT Outcomes: Fall rates, time to first fall, injury rates	Setting: 16 senior centers in Orange County, California Population: 230 older adults who were participants at senior centers	Exercise in conjunction with cognitive behavioral therapy for safety self-awareness	Falls: No effect on fall rates, falls efficacy, or fear of falling. Time to first fall: Longer time to first fall. Injuries: Decreased injuries. Even though a relatively high percentage (38.6 percent) suffered at least one fall, only 7.8 percent of these community-residing elderly required medical attention.
Province 1995115	Exercise-related interventions for fall prevention in the community	Meta-analysis	Design: Preplanned meta-analysis of 7 RCTs Outcomes: Time to each fall (fall-related injury) by self-report and/or medical records	Setting: Two nursing homes and five community sites Population: Patients ages 60–75, ambulatory, cognitively intact	Exercise training one area or more of endurance, flexibility, balance platform, Tai Chi (dynamic balance), and resistance	Falls: Fall rates decreased in group with general exercise (odds ratio = 0.90, 95% CI = 0.81–0.99). Fall rates decreased for those with exercise plus balance training (odds ratio = 0.83, 95% CI = 0.70–0.98). Injuries: Patients who did not exercise had an increase in injurious falls, but power was low to detect this outcome.
Wolf 1997120	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Frailty indicators, occurrence of falls	Setting: Community Population: 200 men and women ≥ 70 years	Tai Chi, computerized balance training, or education	Multiple falls: Risk of multiple falls decreased by 47.5 percent
Steinberg 2000143	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT with four arms Outcomes: Self-reported slips, trips, or falls	Setting: Community, Australia Population: 252 active, community-dwelling Australians ≥ 50 yrs.	Education re: fall risk factors, strength/balance exercises, home safety advice, medical evaluation	Falls: 30 percent reduction in falls; hazard ratio 0.70 (95% CI = 0.48–1.01). Slips: 58 percent reduction in slips; hazard ratio 0.42 (95% CI = 0.29–0.69). Trips: 64 percent reduction in trips; hazard ratio 0.36 (95% CI = 0.26–0.66).
Rubenstein 2000116	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Muscle strength, endurance, mobility, balance, fall rates	Setting: Community-living men Population: 59 men ≥ 65 years with specific fall risk factors	90 min. exercise sessions 3x/week Focus on increased strength and endurance, improving mobility and balance	Falls: Exercise group had lower fall rates than nonexercisers when adjusted for baseline activity level (6 falls/1,000 hours of activity vs 16.2 falls/1,000 hours, P < 0.05). Total number of falls not decreased. Strength: Exercise achieved no significant effect on hip or ankle strength, balance, self-reported physical functioning.
Robertson 2002123	Exercise-related interventions for fall prevention in the community	Meta-analysis	Design: Meta-analysis of four studies Outcomes: Fall rates, injury rates	Setting: Community setting: nine cities and towns in New Zealand Population: 1,016 women and men ages 65 to 97	Muscle strengthening and balance retraining exercises designed specifically to prevent falls	Falls and injuries: Fall and injury rates decreased by 35 percent; no difference between genders. Fall rate incidence rate ratio (IRR) = 0.65, 95% CI = 0.57–0.75 Participants reporting a fall in the previous year had a higher fall rate (IRR = 2.34, 95% CI = 1.64–3.34). Injury rate IRR = 0.65, 95% CI = 0.53–0.81.
Barnett 2003 113	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Fall rates, balance, muscle strength, fear of falling	Setting: Community, South Western Sydney, Australia. Population: 163 subjects ≥ 65 years identified as at risk of falling using a standardized assessment screen by general practitioner or physical therapist	Weekly group exercise program with ancillary home exercises over 1 year	Falls: Fall rates decreased by 40 percent in the exercise group (IRR = 0.60, 95% CI = 0.36– 0.99). Balance measures: Improved in exercise group. Other measures: No difference between groups in strength, reaction time, and walking speed or on Short-Form 36, Physical Activity Scale for the Elderly or fear of falling.
Wolf 2003122	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Time to first fall, fall rates, balance	Setting: 20 congregate living facilities in the greater Atlanta area Population: 291 women and 20 men ages 70 to 97 who were transitioning to frailty	Intense Tai Chi exercise program or wellness education program	Falls: Fall rates decreased in Tai Chi group, but no statistical difference between groups (relative risk = 0.75, 95% CI = 0.52–1.08).
Clemson 2004114	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Fall rates	Setting: Community Population: 310 men and women ≥ 70 years who had had a fall in the previous 12 months or were concerned about falling	Occupational therapy home visits, lower-limb balance and strength training, environmental safety education	Falls: 31 percent reduction in falls for both genders (relative risk = 0.69, 95% CI = 0.50–0.96; P = 0.025). For men alone, 68 percent reduction in falls (relative risk = 0.32, 95% CI = 0.17–0.59).
Morgan 2004140	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Falls	Setting: Community Population: 294 men and women ≥ 60 years who had either a hospital admission or bed rest for 2 days or more within the previous month	Exercise sessions lasting 45 minutes, including warm-up and cool-down, 3 times a week for 8 weeks (24 sessions)	Falls: 49 percent reduction in falls for patients with low baseline physical functioning. 3.5 times increase in falls for patients with high baseline physical functioning.
Suzuki 2004118	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Fall rates	Setting: Community, Japan Population: 52 elderly Japanese women	Exercise intervention— home and community center	Falls: Fall rates decreased in intervention group (13.6 percent v. 54.5 percent; P = 0.0097).
Li 2005112	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcome: Fall rates, functional balance, physical performance, fear of falling	Setting: Community in Portland, Oregon Population: 256 physically inactive elders ages 70 to 92	Tai Chi or stretching 3x/week for 6 months	Falls: 55 percent reduction in falls in Tai Chi group (relative risk = 0.45, 95% CI = 0.30–0.70). Fewer falls in the Tai Chi group (Tai Chi = 38 vs. stretch = 73; P = 0.007), (Tai Chi = 28 percent vs. stretching = 46 percent; P = 0.01). Injuries: Fewer injurious falls (Tai chi = 7 percent vs. stretching = 18 percent; P = 0.03).
Lord 200588	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcome: Fall rates	Setting: Community in Australia Population: 620 people ≥ 75 years	Interventions to maximize vision and sensation or brief advice or usual care	Falls: The rate of falls during the trial period were similar in the three groups. Injuries: The rate of injurious falls during the trial period were similar in the three groups.
Faber 2006125	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Falls, mobility, physical performance, and self-reported disability	Setting: 15 homes for the elderly in Amsterdam, The Netherlands Population: 287 elderly men and women (mean age +/− standard deviation, 85+/− 6yrs)	20-week exercise program of balance training inspired by Tai Chi or daily mobility activities or control	Falls: Fall incidence rate lower in balance training group (2.4 falls/yr) compared to the mobility activities group (3.3 falls/yr) and control (2.5 falls/yr), but not statistically significant. For frail subjects: Risk of becoming a faller in the exercise groups increased almost 3 times (hazard ratio = 2.95; 95% CI = 1.64–5.32). For pre-frail subjects: Risk of becoming a faller decreased by 61 percent (hazard ratio = 0.39; 95% CI = 0.18–0.88).
Lin 2006126	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Falls, fall-related injuries, related functional outcomes	Setting: 6 rural villages in Taiwan: 2 villages received intervention, 4 villages acted as controls Population: 1,200 men and women ≥ 65 years screened; 88 participants	Tai Chi training plus fall-prevention education or fall-prevention education alone	Falls: 50 percent greater decrease in fall rates among the Tai Chi practitioners (relative risk = 0.5; 95% CI = 0.11–2.17), but not statistically significant. Tinetti Balance Scale: Tai Chi practitioners increased by 1.8 points (95% CI = 0.2–3.4). Tinetti Gait Scale: Tai Chi practitioners increased by 0.9 point (95% CI = 0.1–1.8). Fear of Falling: No significant changes in the fear of falling.
Luukinen 2007127	Exercise-related interventions for fall prevention in the community	RCT	Design: RCT Outcomes: Fall rates, time to first fall	Setting: Community, home-dwelling Finnish Population: 555 older men and women (67 percent ≥ 85 years), most with history of recurrent falls or at least one mobility risk factor	Suggestions for a program consisting of home exercise, walking exercise, group activities, self-care exercise, or routine care	For all subjects: Falls: 12 percent decrease in falls from baseline for intervention group (hazard ratio = 0.88, 95% CI = 0.74–1.04). 7 percent decrease in all falls, but not statistically significantly (hazard ratio = 0.93, 95% CI = 0.80–1.09). For subjects not homebound: Falls: 22 percent decrease in falls (hazard ratio = 0.78, 95% CI = 0.64–0.94). 12 percent decrease in first four falls (hazard ratio = 0.88, 95% CI = 0.74–1.05).

‡

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 4

Studies examining physiologic interventions in the community (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type§	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Latham 2003132	Physiologic interventions to prevent falls in patients discharged from acute care to the community	RCT	Design: RCT Outcomes: Falls over 6 months	Setting: Five hospitals in Auckland, New Zealand, and Sydney, Australia Population: 243 frail older people (53 percent female)	One dose vitamin D 300,000 IU versus placebo OR 10 weeks of high-intensity home-based exercise versus attention lessons	Falls: Increase in falls for patients receiving vitamin D as compared to placebo, but not statistically significant (relative risk = 1.12, 95% CI = 0.79–1.59). Decrease in falls for patients in exercise group compared to attention group, but not statistically significant (relative risk = 0.96, 95% CI = 0.67–1.36). Injury: Patients in the exercise group were at increased risk of musculoskeletal injury (risk ratio = 3.6, 95% CI = 1.5–8.0).
Bischoff-Ferrari 2004178	Physiologic interventions to prevent falls and fall-related injuries in the community	Meta-analysis	Design: Meta-analysis of five RCTs Outcomes: Fracture	Setting: Community Population: 1,237 participant in the five studies	Vitamin D: Large dose = 700–800IU/d Small dose = 400 IU/d	Falls: Compared with patients receiving calcium or placebo, vitamin D reduced risk of falling by 22 percent (corrected odds ratio = 0.78, 95% CI = 0.64–0.92). Fracture: Vitamin D 700–800IU/d reduced the risk of fracture by up to 26 percent. Vitamin D 400 IU/d did not reduce fracture risk. Numbers needed to treat: 15 patients would need to be treated with vitamin D to prevent 1 person from falling. Sensitivity analysis of 5 additional studies: Total sample 10,001 – smaller effect size (corrected relative risk = 0.87, 95% CI = 0.80–0.96).
Avenell 2005107		Meta-analysis	Design: Metanalysis of RCTs or quasi-randomized trials Outcomes: Fractures	Setting: Community Poplulation: 7 trials; 18,668 participants	Vitamin D or an analogue alone, or vitamin D with calcium, or Placebo, no intervention, or calcium	Vitamin D or analogue alone: No effect on hip fracture (relative risk = 1.17; 95% CI = 0.98–1.41). No effect on vertebral fracture (relative risk = 1.13; 95% CI = 0.50–2.55). Any new fracture (relative risk = 0.99; 95% CI = 0.91–1.09). Vitamin D or analogue with calcium: Marginal reduction in hip fractures (relative risk = 0.81; 95% CI = 0.68–0.96). Marginal reduction in nonvertebral fractures (relative risk = 0.87; 95% CI = 0.78–0.97). No effect on vertebral fractures. Calcitriol may be associated with an increased incidence of adverse effects.
Grant 2005130	Physiologic interventions to prevent falls and fall-related injuries in the community	RCT	Design: Factorial-design trial Outcomes: New low-energy fractures	Setting: Patients identified in 21 UK hospitals then treated at home after discharge Population: 5,292 people ≥ 70 years (85 percent female) with new low-trauma fracture, and who were mobile before that fracture	800 IU vitamin D daily or 1,000 mg calcium daily or 800 IU vitamin D plus 1,000mg calcium daily or placebo	Falls: No differences between groups (hazard ratio = 0.94; 95% CI = 0.81–1.09). Fractures: No difference between vitamin D and placebo (hazard ratio = 1.02; 95% CI = 0.88–1.19). No difference between combination treatment and placebo.
Sato 2005137	Physiologic interventions to prevent fall-related injuries in acute care	RCT	Design: RCT Outcomes: Vertebral factures, hip fractures	Setting: Community in Japan Population: 500 women ≥ 70 years with Alzheimer’s disease, vitamin D deficiency, and hyperparathyroidism	Risedronate 2.5 with 1,000 IU vitamin D plus 1,200 mg calcium or placebo with 1,000 IU vitamin D plus 1,200 mg calcium	Fractures: 72 percent decrease in fractures in the risedronate group (relative risk = 0.28; 95% CI = 0.13–0.59).
Bischoff-Ferrari 2006134	Physiologic interventions to prevent falls and fall-related injuries in the community	RCT	Design: RCT Outcomes: Fall rates	Setting: Community Population: 199 men and 246 women ≥ 65 years living at home	700 IU of vitamin D plus 500 mg of calcium citrate malate per day or placebo	Falls: Vitamin D plus calcium reduced the odds of falling in women by 46 percent (odds ratio = 0.54, 95% CI = 0.30–0.97). Vitamin D plus calcium reduced the odds of falling in women by 65 percent in less active women (odds ratio = 0.35; 95% CI = 0.15– 0.81). Vitamin D plus calcium did not significantly reduced the odds of falling in men (odds ratio = 0.93, 95 percent CI, 0.50–1.72)
McCloskey 2007138	Physiologic interventions to prevent falls and fall-related injuries in the community	RCT	Design: RCT (double-blind) Outcomes: Hip and any clinical fracture	Setting: General community in South Yorkshire and North Derbyshire Population: 5,579 women ≥ 75 years	800 mg oral clodronate (Bonefos) or placebo	Hip fracture: Slight increase in risk for hip fracture in placebo group (hazard ratio = 1.02, 95% CI = 0.71–1.47). Any fracture: 20 percent decrease in risk for any clinical fracture for patients in clodronate group (hazard ratio = 0.80, 95% CI = 0.68–0.94). Osteoporosis-associated nonhip fractures: 29 percent decrease in clodronate group (hazard ratio = 0.71; 95% CI = 0.57–0.87).

§

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 5

Reviews Examining Fall Prevention Interventions in Acute and Long-Term Care (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type**	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Evans 1998153	Fall and injury prevention in the acute care setting	Literature Review	Design: Review Outcomes: Fall rates	Setting: Acute care Population: Patients in acute care setting	Multiple interventions; 200 studies reviewed	Falls: Across settings, individual interventions are not more useful than fall-prevention programs for a specific subset of patients.
Oliver 2000234	Fall and injury prevention in the acute care setting	Meta-analysis	Design: Systematic review Outcomes: Fall rates	Setting: Acute care Population: Patients in acute care setting	Multiple interventions; 10 studies reviewed	Falls: Overall the interventions studied did not prevent falls (pooled effects ratio = 1.0; 95% CI = 0.60–1.68).
Agostini 200198	Fall and injury prevention in the acute care setting	Review	Design: Review Outcomes: Fall rates	Setting: Acute care Population: Patients in acute care setting	Multiple interventions; two studies and one systematic review reviewed	Falls: Interventions with potential to decrease falls include identification bracelets, bed alarms, special flooring, and hip protectors.
Oliver 2007235	Fall and injury prevention in the acute care setting	Meta-analysis	Design: Systematic review Outcomes: Fall rates, fall-related fracture rate	Setting: Acute care Population: Patients in acute and long-term care setting	Multiple interventions; 43 studies included in meta-analysis	Falls: Multimodal interventions in hospitals showed 18 percent decrease in fall rates (rate ratio = 0.82; 95% CI = 0.68–0.997). Multimodal interventions in hospitals showed no significant effect on the number of fallers. njuries: I Hip protectors in long-term care homes showed a 33 percent decrease in hip fractures (rate ratio = 0.67; 95% CI = 0.46–0.98). Multimodal interventions in hospitals showed no significant effect on the number of fractures. Other interventions: Insufficient evidence to recommend other interventions.

**

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 6

Studies Examining Environmental Interventions in Acute and Long-Term Care (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type††	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Tideiksaar 1993154	Environmental interventions for fall prevention in acute and long-term care	RCT	Design: RCT Outcomes: Bed falls, staff attitudes toward the use of the system	Setting: Geriatric evaluation and treatment unit Population: 70 patients (86 percent female), avg. age 84 years, at risk for falls	Bed alarm system	Falls: Bed alarms reduced falls by 68 percent, but this was not statistically significant (odds ratio = 0.32; 95% CI = 0.10–1.03). The bed alarm system was well accepted by patients, families, and nurses.
Mayo 1994155	Environmental interventions for fall prevention in acute and long-term care	RCT	Design: Blinded RCT Outcomes: Fall rates	Setting: Geriatric care unit at university hospital Population: 70 patients at risk for falls	Identification bracelet for patients at high risk for falls	Falls: Identification bracelets increase fall risk in high-risk patients (hazard ratio = 1.3, 95% CI = 0.8–2.4), but this was not statistically significant.
Kelly 2002240	Environmental interventions for fall prevention in acute and long-term care	Pretest and post-test study	Design: Crossover design for 1 week Outcomes: Fall rates	Setting: Medicare unit of a skilled nursing facility Population: 47 patients at high risk for falls	Movement detection patch attached to the thigh	Falls: Fall rates decreased from 4.0 falls per 100 patient days to 3.4 falls per 100 days for patients with movement detection patches.
Kwok 2006222	Environmental interventions for fall prevention in acute and long-term care	RCT	Design: RCT Outcomes: Physical restraints use, fall rates	Setting: Two geriatric stroke rehabilitation wards in a convalescent hospital in Hong Kong Population: 180 geriatric patients perceived by nurses to be at risk of falls	Bed-chair pressure sensor or control	Falls: No difference in fall rates between chair alarm group and control group. Restraints: No difference in physical restraint use between chair alarm group and control group.

††

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 7

Studies Examining Physical Activity Interventions in Acute and Long-Term Care (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type‡‡	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Mulrow 1994241	Physical activity interventions for fall prevention in acute and long-term care	RCT	Design: RCT Outcomes: Fall rates	Setting: 1academic nursing home and 8 community nursing homes Population: 194 frail long-term care residents	Individually tailored one-on-one physical therapy sessions or Friendly visits	Falls: Fall rates increased in the intervention group (79 versus 60; P = 0.11).
Nowalk 2001244	Physical activity interventions for fall prevention in acute and long-term care	RCT	Design: RCT Outcomes: Fall rates	Setting: 2 long-term care facilities Population: 110 elderly men and women (avg. age 84), capable of ambulating and able to follow simple directions	Resistance-endurance with enhanced exercise or Tai Chi with enhanced exercise or enhanced exercise	Falls and other outcomes: Time to first fall, time to death, number of days hospitalized, and incidence of falls did not differ among the treatment and control groups (P > 0.05).
Choi 2005243	Physical activity interventions for fall prevention in acute and long-term care	Non-randomized trial	Design: A quasi-experimental design with a nonequivalent control group Outcomes: Fall rates	Setting: Residential care facilities Population: 68 fall-prone older adults, avg. age 77.8 years	12-week Sun-style Tai Chi exercise program	Falls: 38 percent decrease in falls in the Tai Chi group, but not statistically significant (relative risk = 0.62; 95% CI = 0.32–1.19).

‡‡

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 8

Studies Examining Multimodal Interventions in Acute and Long-Term Care (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type§§	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Rubenstein 1990242	Multimodal interventions in acute and long-term care	RCT	Design: RCT with 2-year followup Outcomes: Fall rates	Setting: Long-term residential care facility Population: 160 ambulatory subjects (avg. age, 87 years)	Tailored interventions based on fall risk factors	Falls: Patients in the intervention group had 9 percent fewer falls. Fall-related deaths: 17 percent fewer deaths than controls by 2 years, but these trends were not statistically significant.
Bakarich 1997245	Multimodal interventions in acute and long-term care	Pretest, post-test	Design: Pretest, post-test Outcomes: Fall rates	Setting: 450-bed metropolitan teaching hospital Population: 2,023 patients ≥ 70 years	Toileting regimen for at-risk patients (confused and having mobility problems)	Falls: 53 percent less falls during shifts in which the risk assessment and toileting intervention was used.
Lane 1999262	Multimodal interventions in acute and long-term care	Pretest, post-test	Design: Pre-post and comparative, descriptive design Outcomes: Fall rates	Setting: Medical-surgical/critical care unit; large community hospital system Population: 292 older patients	Fall-prevention program	Falls: No decrease in patient fall rate was found between patients who fell before and after implementation of the program.
McMurdo 2000254	Multimodal interventions in acute and long-term care	RCT	Design: RCT Outcomes: Falls and fractures	Setting: Nursing home residents Population: 133 residents ≥ 84 years	Assessment/modification and seated balance exercise training program or reminiscence therapy	Falls: 55 percent reduction in fall rates for group with exercise training, but not statistically significant (odds ratio = 0.45; 95% CI = 0.19–1.14).
Jensen 2002249	Multimodal interventions in acute and long-term care	RCT	Design: cluster RCT Outcomes: Fall rates, time to first fall, fall-related injuries	Setting: 9 residential care facilities located in northern Sweden Population: 439 residential care residents ≥ 65 years	Comprehensive fall risk assessment and tailored interventions	Falls: 51 percent reduction in falls (adjusted odds ratio = 0.49; 95% CI = 0.37–0.65). Injuries: 77 percent reduction in fall-related injuries (adjusted odds ratio = 0.23; 95% CI = 0.06–0.94).
Bischoff 2003247	Multimodal interventions in acute and long-term care	RCT	Design: Double-blind RCT Outcomes: Fall rates	Setting: Long-stay geriatric care Population: 122 elderly women (mean age, 85.3 years; range, 63–99 years)	1,200 mg calcium plus 800 IU vitamin D daily or 1,200 mg calcium daily	Falls: 49 percent reduction of falls in the group that received calcium plus vitamin D (95% CI = 14–71; P < 0.01).
Hofmann 2003250	Multimodal interventions in acute and long-term care	Pretest, post-test	Design: Pretest, post-test Outcomes: Falls, fall-related fractures	Setting: 120-bed nursing home Population: Frail elderly population	Concurrent: Staff education, exercise, and environmental modifications	Falls: 38 percent reduction in fall rates (P = 0.0003). Injuries: 50 percent reduction in injury rates (P > 0.05).
Semin-Goossens 2003257	Multimodal interventions in acute and long-term care	Pretest, post-test	Design: Pretest, post-test pilot study Outcomes: Fall rates	Setting: Academic medical center, 2 medical-surgical units Population: 2,670 patients	Fall prevention guideline with semistructured interventions	Falls: Fall rates in high-risk neurology and medical patients were not reduced.
Haines 2004251	Multimodal interventions in acute and long-term care	RCT	Design: RCT Outcomes: Fall rates, fall-related injury rates, repeat fallers	Setting: 3 subacute wards in rehabilitation and elder care hospital Population: 626 men and women ages 38 to 99 years (avg. 80 years)	Falls risk alert card, exercise, education program, and hip protectors or usual care	Falls: 22 percent decrease in falls (relative risk = 0.78; 95% CI = 0.56–1.06). Injuries: 28 percent decrease in injuries in the intervention group, but not statistically significant (P = 0.20).
Healey 2004253	Multimodal interventions in acute and long-term care	RCT	Design: Cluster randomized trial Outcomes: Fall rates	Setting: Elder care units and associated community units of a district general hospital in England Population: Patients deemed at high risk for falls received intervention	Preprinted care plan for patients identified as at risk of falling and introduced appropriate remedial measures	Falls: 29 percent decrease in falls in the intervention group (relative risk = 0.71; 95% CI = 0.55–0.90, P = 0.006). Injuries: No reduction in injuries.
Jensen 2004249	Multimodal interventions in acute and long-term care	RCT	Design: Cluster-randomized trial Outcomes: Fall rates	Setting: 9 residential care facilities in Sweden Population: 187 residents at high risk for falling ≥ 65 years	Education, environment, exercise, drug review, postfall assessments, hip protectors	Falls: Intervention had no effect on fall rates.
Kerse 2004256	Multimodal interventions in acute and long-term care	RCT	Design: Cluster RCT Outcomes: Fall rates	Setting: Residential care homes Population: 628 residents	Risk assessment followed by tailored interventions	Falls: 34 percent increase in falls (incident rate ratio = 1.34; 95% CI = 1.06–1.72).
Vassallo 2004208	Multimodal interventions in acute and long-term care	Non-randomized trial	Design: Quasi-experimental Outcomes: Fall rates, injury rates, repeat fall rates	Setting: 3 geriatric wards Population: 825 consecutive geriatric patients	Medication adjustment, environmental assessment, wristbands	Falls: 25 percent decrease in falls in the intervention group, but not statistically significant (relative risk = 0.75; 95% CI = 0.53–1.05). No reduction in recurrent fallers. Injuries: No reduction in injuries.
Flicker 2005248	Multimodal interventions in acute and long-term care	RCT	Design: Randomized, placebo-controlled, double-blind trial Outcomes: Falls and fall-related fractures	Setting: Multicenter study in 60 assisted living facilities and 89 nursing homes across AustraliaS Population: 625 residents (avg. age 83 years) with vitamin D deficiency	Vitamin D 10,000 IU once, then 1,000 IU daily plus 600 mg calcium or placebo plus 600 mg calcium	Falls: 27 percent decrease in falls in intervention group (incident rate ratio = 0.73; 95% CI = 0.57–0.95). Injuries: 31 percent decrease in injuries, but not statistically significant (odds ratio = 0.69; 95% CI = 0.40–1.18).
Klay 2005246	Multimodal interventions in acute and long-term care	Pretest, post-test study	Design: Pretest, post-test Outcomes: Urinary tract infections, pressure ulcers, and falls	Setting: Connecticut long-term care center Population: 42 female residents who were incontinent or had urgency related to overactive bladder	Individualized continence program	Falls: 58 percent reduction in falls after treatment with individual continence program.
Fonda 2006260	Multimodal interventions in acute and long-term care	Pretest, post-test study	Design: Pretest, post-test Outcomes: Fall rates, fall-related injuries	Setting: Long-term care setting, Australia Population: All patients admitted to the unit	Multistrategy approach: work practice changes, environmental/equipment changes, staff education	Falls: 19 percent reduction in the number of falls per 1,000 patient days (12.5 v 10.1; P = 0.001). Falls: 77 percent reduction in the number of falls resulting in serious injuries per 1,000 patient days (0.73 v 0.17; P < 0.001).
Schwendimann 2006261	Multimodal interventions in acute and long-term care		Design: Serial survey design Outcomes: Fall rates, fall-related injuries	Setting: 300-bed urban public hospital Population: Adult patients in internal medicine, geriatrics, and surgery	Interdisciplinary falls-prevention program	Falls: Decrease in fall rates, but not statistically significant (pre-9.0, post-7.8; P = 0.086). Injuries: No change in injury rate.

§§

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Evidence Table 9

Studies Examining Interventions to Prevent Injury in Acute and Long-Term Care (listed chronologically)

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Source	Safety Issue Related to Clinical Practice	Design Type***	Study Design, Study Outcome Measure(s)	Study Setting & Study Population	Study Intervention	Key Finding(s)
Lauritzen 1993263	Physical interventions to prevent fall-related injuries in acute care	RCT	Design: RCT Outcomes: Hip fractures	Setting: 10 of the 28 wards in a nursing home Population: 665 older patients (67 percent female)	External hip protectors	Fractures: 56 percent decrease in hip fractures for patients wearing hip protectors (relative risk = 0.44; 95% CI = 0.21–0.94).
O'Halloran 2004264	Physical interventions to prevent fall-related injuries in acute care	RCT	Design: Cluster RCT Outcomes: Hip fracture	Setting: 127 nursing and residential homes in Northern Ireland Population: 4,117 elderly residents	Hip protectors, staff education	Fractures: Slight increase in hip fractures in the intervention group (adjusted rate ratio = 1.05; 95% CI = 0.77–1.43).
Ray 2005266	Multimodal interventions to prevent fall-related injuries in acute care	RCT	Design: Cluster RCT Outcomes: Serious fall-related injuries	Setting: 112 long-term care facilities Population: 10,558 residents ≥ 65 years, not bedridden	Staff safety education plan with tailored interventions	Injuries: No difference in injury rates (adjusted rate ratio = 0.98; 95% CI = 0.83–1.16). 21 percent decrease in injury rates for patients with prior fall in facilities with the best compliance, but not statistically significant (adjusted rate ratio = 0.79; 95% CI = 0.57–1.10).
Sato 2005136	Physiologic interventions to prevent fall-related injuries in acute care	RCT	Design: Double blind RCT Outcomes: Hip fractures	Setting: Stroke unit at hospital in Japan Population: 280 male poststroke patients ≥ 65 years	Risedronate 2.5 mg or placebo	Fractures: 81 percent decrease in hip fractures in risedronate group (relative risk = 0.19, 95% CI = 0.04–0.89).
Sato 2005137	Physiologic interventions to prevent fall-related injuries in acute care	RCT	Design: Double blind RCT Outcomes: Hip fractures	Setting: Stroke unit at hospital in Japan Population: 187 female poststroke patients ≥ 65 years	Risedronate 2.5 mg or placebo	Fractures: 86 percent decrease in hip fractures in the risedronate group, but this was not statistically significant (relative risk = 0.14; 95% CI = 0.02–1.2).

***

Study Design Type: (1) Meta-analysis, (2) Randomized controlled trials, (3) Nonrandomized trials, (4) Cross-sectional studies, (5) Case control studies, (6) Pretest and post-test (before and after) studies, (7) Time series studies, (8) Noncomparative studies, (9) Retrospective cohort studies, (10) Prospective cohort studies, (11) Systematic literature reviews, (12) Literature reviews, nonsystematic/narrative, (13) Quality-improvement projects/research, (14) Changing-practice projects/research, (15) Case series, (16) Consensus reports, (17) Published guidelines, (18) Unpublished research, reviews, etc.

Falls and Related Injuries in the Acute and Long-Term Care Settings

Fall and related injury prevention is a major focus for both acute and long-term health care organizations. In 2005, the Joint Commission added the requirement for fall risk assessment and periodic reassessment as a National Patient Safety Goal in the acute care setting.⁵⁴ The goal of this requirement is to ensure that all patients are screened for falls and thus seeks to reduce harm from falls. However, the outcome is unpredictable because fall and injury risk assessment instruments have shown inconsistent reliability and validity A more promising extension of this goal starting in 2006 and continuing forward is the additional requisite of implementing and evaluating a fall-prevention program.¹⁴⁶ National compliance with these goals has the potential to significantly impact the problem of falls in the acute care setting. Efforts to enhance quality of care in the long-term care environment via improved reporting have the potential to reduce falls and related injuries in these particularly vulnerable patients; however, the successful implementation of fall-prevention programs will be necessary to improve the problem.

Falls in the acute and long-term care settings have several possible consequences. Recurrent falls have been identified as contributing to increases in the length of stay (LOS) in elderly psychiatric patients.¹⁴⁷ However, some research has suggested that LOS itself may be a predictor. A fall may also lead to a poorer quality of life because of fallophobia, a fear of future falls, which may itself contribute to fall risk.¹⁴⁸ Injuries occur in between 6 and 44 percent of falls in the acute care setting.^{20, 21, 23} In the long-term care population, between 9 and 15 percent of falls result in injury, with approximately 4 percent of these falls resulting in fractures.¹⁴⁹ Additionally, patients who have underlying disease states are more susceptible to injuries; for example, osteoporosis can increase the risk for fracture, and bleeding disorders can increase the risk for subdural hematomas.¹⁵⁰ Moreover, fall-related injuries increase resource utilization: injuries from falls lead to increased LOS and an increased chance of unplanned readmission or of discharge to residential or nursing home care.¹⁵¹ Furthermore, inpatients who have incurred an injury due to a fall have approximately 60 percent higher total charges than those who did not fall or those who fell and did not sustain an injury.¹⁵²

Evans and colleagues,¹⁵³ via the Joanna Briggs Institute, performed a systematic review of the evidence up to 1997 for fall and injury prevention in the acute care setting. They examined 200 studies related to identification of predictors, risk assessment instrument development and testing, and fall- and injury-prevention interventions. Of these studies, only two were randomized controlled trials (RCTs). The trial by Tideiksaar and colleagues¹⁵⁴ examined the use of bed alarms to notify staff when patients at high risk for falls got out of bed; however, this study had a sample size that was too small to identify an effect from using bed alarms. The other RCT examined the use of colored bracelets to identify patients at high risk for falls. Again, the study results were inconclusive.¹⁵⁵ Evans and colleagues concluded that the fall risk assessment instruments available were not generalizable. However, they did not adequately compare the psychometric properties of the instruments in question; rather they evaluated research related to the implementation of such instruments, which was relatively weak up to that time. In addition, Evans and colleagues concluded that individual interventions were not more useful that any of the fall-prevention programs that might be developed at a particular institution for a specific subset of patients. However, recent research has seen a growing number of RCTs, which will facilitate the ability to make stronger practice recommendations for this complex and challenging problem.

For this review, research related to falls and related injuries in the acute and long-term care settings were identified and categorized as follows: risk factor identification, risk assessment instruments, and prevention strategies. Each category of research is discussed below.

Acute care and long-term care risk factors

Factors associated with patients at risk of falling in the acute care setting have been explored extensively, particularly over the past two decades.^{17, 87, 156–160} Evans and colleagues¹⁶¹ conducted a systematic review of research and identified 28 risk factors for falling, including impaired mental status, special toileting needs, impaired physical status, and to some extent age and medications. Oliver and colleagues¹⁵⁹ reviewed risk factor and risk assessment literature and identified five risk factors consistent across studies: unsteady gait, increased toileting needs, confusion, sedative-hypnotics, and history of falling. In the long-term care environment, risk factors are largely the same, with the addition of inability to transfer effectively¹⁶² and short-term memory loss.¹⁶³ Although ability to transfer and short-term memory function might be characterized by unsteady gait and confusion, these items are expressly captured via the LTCMDS.

Research has consistently demonstrated that multiple factors are associated with falling in elderly and hospitalized patients and that fall risk increases as the number of factors increases.^{98, 153, 156–159, 164–166} Although increased age is a strong predictor of falling in the community, increased age has not always been identified as a predictor in the acute care setting. Some studies have found increased age to be a risk factor,^{17, 165} but others have found that increased age is not a factor in acute care.^{157, 167, 168} Comorbidities and impaired functional status may be more important predictors of falls and subsequent injury in this setting.^{150, 157} Recent work by Hendrich¹⁶⁹ did not support the association between increasing age (older than 65 years) and increasing risk of falling in the inpatient environment. Instead, Hendrich and colleagues¹⁶⁹ found that confusion was the most important risk factor associated with the risk of falling. Nevertheless, age must be considered when discussing injury associated with falls because often with age comes frailty. Several researchers have identified gender as a risk factor, with female gender being a stronger risk factor in the older population¹⁷⁰ and male gender a stronger factor in the younger population.^{167, 169, 171} A recent retrospective analysis by Krauss and colleagues¹⁷⁰ found that altered mental status was not a factor in falls, but that patients in academic medical centers were more likely to fall. This research was limited because it did not control for patient acuity or staffing levels.

Harwood and colleagues^{172, 173} reviewed the literature related to visual problems and falls and found that uncorrected visual impairment nearly doubled the risk of falling. Cardiovascular causes of falls derive predominantly from neurally mediated disorders (e.g., vasovagal syncope) and cardiac abnormalities (e.g., arrhythmias, infarction, valvular stenosis).^{174, 175} Time of day has also been implicated; Tutuarimia and colleagues¹⁷⁶ identified a higher rate of falls on the night shift, but this is inconsistent with other research and may in fact be explained by staffing patterns. Association of falls to the lunar cycle has also been explored, but no association was found.¹⁷⁷

Vitamin D deficiency has been implicated as a risk factor for falls and fracture in the long-term care setting.¹⁷⁸ In addition, elevated alkaline phosphatase and low serum parathyroid hormone have been identified as predictors for falls,^{179, 180} and anemia has also been implicated.¹⁸¹

A number of researchers are exploring the relationship between nurse-to-patient staffing ratios and an increase in the incidence of falls.^{20, 176, 182–184} Some of this work has identified an inverse association between licensed nurse staffing ratios and fall rates (i.e., a higher proportion of nurses is associated with lower fall rates);^{176, 182, 184, 185} however, the overall the results are inconclusive.¹⁸⁶ In addition, a growing body of research related to failure to rescue, defined as being “based on the premise that although deaths in hospitals are sometimes unavoidable, many can be prevented,”^187–189 supports the inclusion of unanticipated physiologic events in the definition of falls since the patient’s safety issues should be addressed at all times. Other researchers examining nurse staffing ratios and fall rates suggest that fall rates are reduced by increasing the number of nurse aids rather than licensed nursing staff.¹⁹⁰ This is potentially supported by recent work by Krauss and colleagues;¹⁹¹ of the fallers in their case-control study, 85 percent of those in need of assistance or supervision with ambulation fell while not being supervised.

Certain subgroups of patients have been identified at higher risk because of the inherent characteristics of their disease process or treatment modalities. These groups include geriatric, behavioral health, oncology, rehabilitation, stroke, and multiple sclerosis patients. In the behavioral health setting, fall rates range from 4.5 to 25 falls per 1,000 patient days.^{192, 193} Researchers have identified the typical faller in the behavioral health setting as a female with a history of falls; who was younger than 65 years of age; who was experiencing anxiety and agitation; and who was receiving a sedative, a tranquilizer, or a laxative.¹⁹⁴ Irvin¹⁹⁵ explored risk factors in the psychiatric setting and found that gait or balance problems and history of falls were the primary predictors. Although many of these characteristics are consistent with patients in the acute care setting, younger age and comorbidities such as depression and psychosis are often predictors in the behavioral health population.^196–199 In addition, treatments specific to behavioral health patients are different than those in the acute care setting. For example, patients being treated for late-life depression are at risk for falling in the first weeks of using a tricyclic antidepressant and should be monitored closely while they are adjusting to the new medication.⁷⁵ De Carle and Kohn^{200, 201} have described risk factors in behavioral health patients and have identified electroconvulsive therapy as a predictor.

Patients in rehabilitation units are also at higher risk, likely because they have suffered neurological injuries such as stroke or head injury, which precipitate muscle weakness, impaired cognition, and impulsivity.^202–205 In addition, these patients are being physically challenged, which places them in higher-risk situations and thus at greater risk for falling.²⁰⁶

In the pediatric inpatient setting, fall rates range from 0 to 0.8 per 1,000 patient days.²⁰⁷ These rates are very low compared to adult inpatient and long-term care rates. The factors that limit the number of falls in this population are unclear, but may be related to increased supervision of pediatric patients via higher nurse-to-patient staffing ratios and the common practice of parents staying with pediatric inpatients.

Injury risk factors in the acute and long-term care setting

In general, injury risk factors are similar across care areas. Vassallo and colleagues²⁰⁸ examined the risk factors associated with injury in a group of inpatient fallers and found that three factors were associated with injuries related to falls: (1) history of falls, (2) confusion, and (3) unsafe gait. In addition to these, Rothschild and colleagues¹³⁴ identified physiological processes, such as increased bleeding tendencies and osteoporosis, as factors that increased risk for bleeding or fracture. The risk for medications or physiologic factors to precipitate injuries related to bleeding have been explored on a limited basis in the inpatient population. Contrary to results in the community,⁸⁴ Stein and team²⁰⁹ found that hospitalized stroke patients who are anticoagulated are not at higher risk for injury than nonanticoagulated patients; however, this study was small and the issue warrants further research. Bond and colleagues²¹⁰ examined over a 4-year period the risk for bleeding injury among 1,600 patients who fell while hospitalized. These researchers found that half of the patients were on thrombotic therapy and that the incidence of fall-related intracranial hemorrhage was low, even in persons taking warfarin. The authors suggested that selection bias may be a factor because physicians might withhold anticoagulant therapy for patients who have a higher fall risk. More recently, Spector and colleagues²¹¹ performed a large study of nursing homes and found that 85 percent of fractures were caused by falls, and that those with epilepsy, those with agitation, and those taking anticonvulsants had the highest risk of sustaining a fracture if they fell.

Table 2

Risk Factors for Falls and Injuries in Acute and Long-Term Care

Acute care risk assessment instruments

Many tools have been developed to identify patients at highest risk for falling in the acute care setting.^{21, 159, 167, 169, 212–215} Perell and colleagues⁸⁷ reviewed risk assessment tools and identified 6 functional assessment instruments and 15 fall risk assessment instruments developed by nursing. Vassallo and colleagues²¹⁶ concurrently examined the predictive validity in the acute care setting of four commonly used risk assessment instruments (STRATIFY, Downton, Tullamore, and Tinetti) and found that the STRATIFY instrument was the easiest to use, was most effective of the four at predicting falls in the first week of inpatient admission (total predictive accuracy of 66.6 percent), but had the poorest sensitivity (68.2 percent).

The most commonly reported risk assessment instrument is the Morse Falls Risk Assessment Tool.²¹⁷ In 2002, O’Connell and Myers²¹⁸ conducted psychometric testing with this tool on 1,059 patients admitted to an Australian hospital. In this study, the Morse Falls Risk tool had a sensitivity of 83 percent and a specificity of 29 percent, but a positive predictive value of only 18 percent. This resulted in a very high false-positive rate, with the tool identifying more than 70 percent of patients who did not fall at high risk for falling. This research was confounded by the fact that the interventions were applied based on the instrument’s predictions; therefore, the predictive validity cannot be conclusively stated. The STRATIFY Falls Prediction tool also had a low positive predictive value (30 percent) and relatively low sensitivity (66 percent) and specificity (47 percent).²¹²

The Heinrich Falls Risk Model I is reported to be more robust (sensitivity, 77 percent; specificity, 72 percent) than either of the others, and the Hendrich Falls Risk Model II demonstrated even more improvement (sensitivity, 74.9 percent; specificity 73.9, percent; positive predictive value, 75 percent).¹⁶⁹ The inclusion of a Get Up and Go test in the Heinrich II tool was the major change between version I and version II. The Get Up and Go test evaluates a person’s ability to rise from a chair in a single movement, which is an assessment method that has been explored in earlier fall-prediction research. It is surprising that the sensitivity and specificity of the tool increases only slightly with the addition of this factor, underscoring the complexity of predicting patient falls. In addition, prospective evaluation of the use of the Hendrich II instrument has yet to be reported.

Several studies have tested the predictive validity of fall risk assessment instruments in relation to the judgment of nurses. Myers and Nikoletti²¹⁹ concluded that neither the fall risk assessment instrument nor nurses’ clinical judgment acted as a reliable predictor. Eagle and colleagues²²⁰ compared the Functional Reach test, the Morse Falls Scale, and nurses’ clinical judgment in the rehabilitation and geriatric environment. This study also concluded that the two standardized assessment processes were no better at predicting falls than the clinical judgment of nurses. A limitation in both of these studies was that the evaluation occurred only at one time point close to admission, which does not account for the variability of patient status throughout a patient’s hospital stay.

In the domain of rehabilitation medicine, Ruchinskas²²¹ compared structured assessments—including the Mini-Mental State Exam, the Geriatric Depression Scale, the Functional Intervention Model, and the clinical judgment of physical and occupational therapists—on admission and discharge. This study concluded that the clinical judgment of therapists had a positive predictive power of 33 percent and a negative predictive power of 82 percent. However, the more accurate predictors of falling for the patients in their sample were a history of falls and presence of a neurological diagnosis. In the residential care environment, Lundin-Olson and colleagues²²² found that clinical judgment can contribute to the accurate prediction of fall risk, but is not sufficient on its own as a valid predictor.

Although fall-prediction research has been performed for two decades, it is clear that fall prevention is a complex problem that cannot be solved by risk assessment alone, hence the dissatisfaction with available risk assessment instruments.

Long-term care assessment instruments

Lundin-Olson and colleagues²²³ developed the Mobility Interaction Fall Chart (MIF chart), which is an instrument based on a patients’ ability to walk and talk at the same time, the ability to maintain pace while carrying a glass of water, visual impairment, and difficulty concentrating. When the predictive validity of the MIF chart was evaluated, the researchers found that the chart was helpful only when used in conjunction with clinical judgment and knowledge of a patient’s history of falls, thus making the use of this instrument on its own limited.²²²

The Downton instrument, originally developed in the community setting, characterizes risk by five factors: (1) increased dependency, (2) cognitive impairment, (3) increased number of physical symptoms, (4) presence of anxiety, and (5) presence of depression.²²⁴ This instrument has recently been prospectively evaluated in the long-term care setting with a reported sensitivity ranging from 81 to 95 percent and specificity ranging from 35 to 40 percent.²²⁵ Although the specificity is low, this instrument might provide a standardized measure to identify those at risk in the long-term care environment.

Becker and colleagues¹⁶² have recently described an algorithm to assess fall risk in the long-term care setting, categorizing long-term care residents into three subgroups: (1) residents requiring assistance to transfer, (2) residents able to transfer with history of falls and requiring the use of restraints, and (3) residents able to transfer and with no history of falls but with urinary incontinence and visual impairment. The researchers found that the residents with the history of falls were at highest risk for falls, which is consistent with other research in this domain, but might be useful to tailor interventions and would warrant prospective evaluation.

Acute care pediatric risk assessment instruments

Falls in the acute care pediatric setting are relatively rare; however, standardized assessment may be beneficial to reduce falls and injuries in this population. Graf²⁰⁷ has recently developed an instrument for acute care pediatric risk assessment. According to Graf, factors associated with pediatric falls include (1) seizure medication (odds ratio 4.9), (2) orthopedic diagnosis, (3) not using an IV (odds ratio 3.6), (4) physical/occupational therapy ordered, and (5) LOS (odds ratio 1.84 for every 5 days). This model has a sensitivity and specificity of 69 percent and 84 percent, respectively, and is being prospectively evaluated by the investigator with the hope that standardized assessment will facilitate reduction in these already-low rates.

Automated risk assessment in the acute and long-term care settings

Recent national patient safety efforts highlight the promise of using informatics processes to manage patient safety issues such as the management of patient falls. However, to date, most automated risk assessment techniques in the acute care setting are electronic versions of existing fall risk assessment instruments, with limited use of computerized decision support.^{167, 226, 227} Promising new work in data mining for fall prediction has demonstrated that use of the LTCMDS has the potential to use existing data to generate risk models for patients in this setting. Volrathongchai²²⁸ has recently explored the ability to use computerized data mining techniques to identify elderly residents of long-term care facilities who were at risk for falls. Although this work has not been prospectively evaluated, the research found that the use of these data mining techniques, in conjunction with nursing knowledge, had the potential to identify fallers.

Acute and long-term care prevention strategies

The goal of any fall- and injury-prevention effort is to decrease adverse outcomes for the patients who are most vulnerable to falling. A beneficial consequence of fall- and related-injury-prevention programs is the potential to streamline resource use, with the added potential for decreased costs associated with this problem.^229–231 To date, however, a ubiquitous fall- and injury-prevention strategy has not been identified for hospitalized patients, and implementation of multifaceted strategies is often difficult to introduce in the complex clinical environment.²³²

Several reviews have examined fall-prevention strategies in the acute and long-term care settings.^{98, 99, 153, 159, 233} Oliver, Hopper, and Seed²³⁴ examined 10 studies, including 3 RCTs and 7 prospective studies with historical controls. Oliver and colleagues found that the pooled effects ratio was 1.0 (95% CI = 0.60–1.68), indicating that overall the interventions were not able to prevent falls. More recently, Oliver and colleagues²³⁵ have performed a meta-analysis of fall- and injury-prevention strategies and found a decrease in fall rates with multimodal intervention and a decrease in hip fractures with hip protectors in the long-term care setting. Agostini, Baker, and Bogardus⁹⁸ conducted a review of the literature related to fall prevention for hospitalized and institutionalized older adults. This review did not pool the results, but examined the literature related to the use of armbands, bed alarms, and restraints for fall prevention, all of which will be discussed individually below.

The use of physical restraints to prevent falls has been refuted because restraints limit mobility, contribute to injuries, and don’t prevent falls.^{236, 237} Agostini and colleagues⁹⁸ examined literature related to fall prevention via restraint and side rail use, as well as fall rates when restraints were removed. Six studies found that restraints were associated with increased injuries, and restraint and side rail removal did not increase fall rates. Evans, Wood, and Lambert²³⁸ also examined the literature and found 16 studies that examined restraint minimization, concluding that restraint-minimization programs involving effective staff education can reduce injuries and do not increase fall rates.

Several individual fall-prevention interventions have been examined, including the use of armband identification bracelets, exercise regimen, postfall assessment, bed alarms, toileting regimen, and vitamin D supplementation. Mayo and colleagues¹⁵⁵ conducted a randomized controlled trial to examine if armbands would help identify high-risk patients in a rehabilitation unit and prevent falls in the high-risk group. The researchers, however, found that high-risk patients with a blue armband had higher fall rates than those without the armband. Despite widespread use, only one study from 1993 has examined bed alarms. Tideiksaar and colleagues¹⁵⁴ found that bed alarms were an effective method for fall prevention (relative risk = 0.32), but the intervention warrants further research. An associated intervention, a movement detector, has recently been developed. Kwok and colleagues²³⁹ studied movement detectors and found no difference between intervention and control groups. However, a pilot study examined the use of a movement detection patch attached to the thigh, which alerts clinicians when elderly long-term care residents are moving about.²⁴⁰ Kelly and colleagues found a 91 percent decrease in falls during the 1-week testing period. Although this study quality was poor, the intervention might be suitable for select patients and bears further testing. Rask and colleagues²²⁴ and Taylor and colleagues²²⁵ evaluated the use of a fall-prevention program with a fall coordinator in the long-term care setting; they found that the control nursing homes had increases in fall rates over 4 years, whereas the intervention nursing homes had stable fall rates during the same time period.

Mulrow and colleagues²⁴¹ examined the effects of a physical therapy exercise intervention for frail long-term care residents and found that fall rates increased in the intervention group. However, the intervention group in this study also showed an increase in general strength and a decrease in the use of assistive devices, making one wonder if the physical therapy intervention sought to decrease the use of assistive devices in inappropriate situations. Rubenstein and colleagues²⁴² examined the ability for post-fall assessment to identify underlying factors that could be remedied to prevent further falls. Choi and colleagues²⁴³ examined the effect of Tai Chi in the long-term care setting and found a 38 percent decrease in falls in the Tai Chi group, but this was not statistically significant (relative risk = 0.62; 95% CI = 0.32–1.19). A larger study may demonstrate statistical significance. A more recent study by Nowalk²⁴⁴ reported no difference between groups who received strength training. The authors concluded that long term care residents may require individualized training, rather than group training.

Bakarich, McMillan, and Prosser²⁴⁵ examined the impact of a toileting regimen for elderly confused patients with mobility problems in the acute care units of a large metropolitan teaching hospital. The researchers found that there were 53 percent fewer falls during shifts in which the risk assessment and toileting intervention was used, but that compliance with the assessment and intervention was difficult to maintain. More recently, Klay and Marfyak²⁴⁶ found that a continence specialist in the long-term care environment reduced falls by 58 percent. Vitamin D has also reduced falls in elderly females in the long-term care setting by up to 49 percent, and in both males and females by 25 percent.^{129, 134, 178, 247, 248} Further investigation of the use of vitamin D in the acute care and rehabilitation setting for fall and injury prevention is warranted. Jensen and colleagues²⁴⁹ examined the effect of exercise training on elderly residential care patients and found an increase in strength and balance, and a nonstatistically significant decrease in falls. This study was limited by its small sample size and unequal distribution of important risk factors such as Mini-Mental State Exam scores across groups.

As with community interventions, tailored, multipronged prevention strategies are being shown to be more effective in acute and long-term care settings than individual interventions alone. Hofmann and colleagues²⁵⁰ used three concurrent interventions—staff education, an exercise program, and environmental modifications—for a frail elderly population. The concurrent use of these interventions decreased the fall rate by 38 percent and decreased the fracture rate by 50 percent. Haines and colleagues²⁵¹ also examined a multipronged intervention involving staff and patient education, an exercise program, and the use of hip protectors. Researchers found a 22 percent decrease in falls and a 28 percent decrease in injuries in the intervention group.

One of the most promising studies by Jensen and her research team²⁵² investigated the effects of a comprehensive fall risk assessment and tailored intervention program in the long-term care setting. The intervention included assessment via the Mobility Interaction Fall Chart, visual evaluation, medication evaluation, and delirium screening by all members of the care team—physicians, nurses, and physical and occupational therapists. This research demonstrated that the comprehensive assessment and tailored interventions reduced falls by 51 percent and injuries by 77 percent over a 34-week period. Healy and colleagues²⁵³ also found a statistically significant reduction in falls (RR = 0.71) by applying a tailored plan of care to adult inpatients who were deemed at high risk for a fall based on having had a previous fall. In effect, this research used history of fall as a method to triage high-risk patients, who then received a comprehensive risk assessment with targeted interventions. This research did not demonstrate a decrease in injuries; however, further research using this technique will be useful. McMurdo, Millar, and Daly²⁵⁴ found up to a 55-percent reduction in fall rates in a group of 133 nursing home residents with comprehensive risk assessment and balance training, but these results were not statistically significant. A larger sample size would provide a better understanding of the effect of the intervention.

Other research examining multimodal interventions have had mixed outcomes. A recent study by Vassallo and colleagues²⁵⁵ in long-term care facilities found a decrease in falls was nullified when the results were controlled for LOS. However, controlling for LOS removes the ability for LOS to be identified as a predictor, which may be the case for patients who stay longer in a hospital setting. Kerse and colleagues²⁵⁶ found that in a group of nursing homes, long-term care residents who were randomized to risk assessment followed by tailored interventions showed an increase in falls (incident rate ratio = 1.34; P = 0.018). Semin-Goossens, van der Helm, and Bossuyt²⁵⁷ evaluated the effect of a guideline with semistructured interventions and found that fall rates in high-risk neurology and medical patients were not reduced. The researchers attributed the failure of the program to resistance by nurses to changing attitudes toward falls with the statement that nurses did not find falls troublesome enough. However, the failure was more likely due to system issues, such as ability to implement and agreement with the guideline, and training issues, which are common with guideline implementation failures.^{258, 259} In addition, the Semin-Goossens guideline did not use a standardized risk assessment instrument, which might have made it difficult to identify patients at risk. Fonda and colleagues²⁶⁰ studied a multimodal process-improvement plan and found that after 3 years, fall rates were decreased by 19 percent and injuries were decreased by 77 percent. Furthermore, this effect was sustained with continued use of the multimodal intervention. Schwendimann and others²⁶¹ found a moderate, but not statistically significant decrease in fall rates, and no change in injury rates after implementing an interdisciplinary fall-prevention program. Lane²⁶² found no decrease in patient fall rates before and after implementation of a fall-prevention program. Although the results of multimodal studies are conflicting, it is important to note that none of the studies of multimodal interventions—whether effective or ineffective results—controlled for staffing ratios or skill mix.

An increasing number of studies are examining the prevention of injury in the acute and long-term care settings. Hip protectors have been evaluated in the long-term care environment since the early 1990s. Although early work found that hip protectors were effective in reducing hip fractures in the frail or osteoporitic elderly,²⁶³ more recent work indicates that compliance with using hip protectors is difficult to maintain, making recommendation for hip protector use conditional.^{264, 265} Ray and colleagues²⁶⁶ examined the ability of a 2-day staff safety education plan to reduce serious fall-related injuries and found that this intervention was not effective, but the result may have been confounded by lack of staff compliance with the safety plan. (See Evidence Tables 1 to 9 for individual study results.)

Summary of acute and long-term care falls and related injuries

In summary, fall prevention in the acute and long-term care settings is a complex and demanding problem with multiple patient types and risk factors to manage. Standardized risk assessment with multimodal tailored interventions appears to be the most successful method of prevention; however, implementation of comprehensive interventions across care settings can be challenging. Further research toward overcoming barriers to implementation, guideline adherence, staffing ratios, and tailored interventions for newly identified risk factors such as vitamin D deficiency and anemia are warranted. Furthermore, research must be conducted on a larger scale to demonstrate generalizability and to be able to translate evidence into practice.

Evidence-Based Practice Implications

Screening for fall and injury risk should be performed across settings. In the community, all patients older than 65 years should be screened, and in the home care, acute care, and long-term care settings, patients of all ages should be screened. Screening needs to include injury risk, not just fall risk. The most effective interventions are multimodal ones that address specific areas of risk and work with interdisciplinary fall-prevention teams.

In the community, screening can take place with a general annual physical exam or other routine health care visit. A standardized risk assessment tool should be used, such as the Tinnetti screening tool, which has the highest sensitivity and specificity for use in the community, but screening for injury risk must be included. If a patient is seen in an emergency room because of a fall, evidence suggests that focused fall and injury risk evaluation is warranted, especially if the patient is to be discharged home, i.e., the discharge prescription should include a focused fall risk assessment by the primary care provider or by a fall-prevention clinic. Tailored interventions for elderly community dwellers can decrease fall rates. Interventions that have had the most success in the community include exercise interventions with leg strengthening and balance training (e.g., Tai Chi), medication adjustment, management of cardiac-related syncope, effective diabetes management, management of vitamin D deficiency, and home safety modifications. Interventions to prevent injury in the community include calcium with vitamin D for fracture prevention, and additional fall precautions and increased screening for patients on anticoagulant therapy.

In the acute and long-term care settings, screening should be carried out using a standardized assessment tool for all patients. The Morse tool is the most commonly used in the acute care setting, but it does not screen for injury risk. In the long-term care setting, the LTCMDS may be an effective screening tool. In both acute and long-term care, effective interventions are multimodal and include medication adjustment, environmental adjustment, alarm devices, staff safety education, calcium and vitamin D, exercise interventions, and treatment of other underlying disorders. Interventions to prevent injury in the acute and long-term care settings include limiting restraint use, lowering bedrails, using hip protectors in long-term care, calcium with vitamin D, and possibly bisphosphonates in long-term care. Across the health care continuum, effective interventions have been identified, but their use is not ubiquitous.

Research Implications

In the community setting, identification of the best timing for screening and reassessment is needed. Identification of methods to build fall- and injury-prevention programs in the community is needed to guide policymakers. In the acute and long-term care settings, large multisite intervention studies that use multimodal interventions tailored for individual risk factors and that control for comorbidities, acuity, staffing, and other environmental factors are needed. Cost-effectiveness studies to characterize the impact of fall- and injury-prevention programs are needed in the acute and long-term care settings.

Recommendations From Evidence-Based Practice and Research Implications

1. Recommendations for screening and assessment

• Fall and injury risk screening should be performed in all settings.
• All patients who fall should receive a comprehensive postfall assessment.
• Methods for computerized screening and followup should be explored.

Table 3

Recommendations for Screening and Assessment

2. Recommendations for interventions in the community setting

• Apply multimodal interventions as identified by risk assessment.
• Participate in national reporting activities such as ANA–NDNQI.
• Examine the use of computer-based guidelines in all settings.

Table 4

Recommendations for Community Setting

3. Recommendations for interventions i n the acute and long- term care settings

• Apply multimodal interventions as identified by risk assessment.
• Participate in national reporting activities such as ANA–NDNQI.
• Examine the use of computer-based guidelines in all settings.
• Large, multi-site randomized controlled trials that evaluate tailored interventions while controlling for organizational culture, staffing, comorbidities, acuity, and other factors are needed. Injury rates should be the primary outcome of interest, since fall-rate reporting may be an imprecise measure.
• Characterize the cost effectiveness of bundles of tailored interventions.

Table 5

Recommendations for Acute and Long-Term Care

Conclusion

Falls and related injuries are an important issue across the care continuum. National efforts in the community via Healthy People 2010, in the acute care setting via the Joint Commission’s National Patient Safety Goals, and in the long-term care setting via the Nursing Home Quality Initiative project have the potential to significantly reduce falls and related injuries. The growing number of randomized controlled trials related to fall-prevention efforts is promising. However, most of these studies have been carried out in the community and long-term care environments, with few randomized controlled trials evaluating fall- and injury-prevention measures in the acute care setting. As with other nursing-sensitive quality indicators, recent research demonstrating an association between fall rates and nurse staffing ratios needs to be more fully explored. In addition, further research needs to explore automated methods of assessing and communicating fall risk, better methods for risk identification, and the identification of prevention measures. Indeed, with coordinated efforts to apply the evidence to practice, the problem of falls might be managed more effectively.

Search Strategy

MEDLINE,^® the Cumulative Index to Nursing and Allied Health Literature (CINAHL^®), and Cochrane databases from inception to March 2007 were searched for medical subject heading terms, both individual terms and combinations of the following: accidental falls, patient safety, medical errors, nursing-sensitive quality indicators, and fall prevention. In addition, references from relevant articles were searched using the snowball technique, as were archives of select nursing research and gerontology journals. The Related Links function in MEDLINE was also used to maximize the search strategy. Google, Google Scholar, and citations from identified articles were also searched for additional possible references. Articles related to occupational falls, sports-related falls, alcohol-related falls, and physical abuse-related falls were excluded. Articles that reported physiologic characteristics that are suspected to preclude falls but that did not examine falls or fall-related injuries as outcomes were also excluded because the causative effect on falls and fall-related injuries is, to date, inconclusive. Further, articles that were published in a foreign language were excluded. Two hundred and twenty seven articles were reviewed. Sixty-one of these were intervention research studies related to fall and injury prevention (32 from the community setting; 33 from the acute and long-term care setting).

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