United States Department of Veterans Affairs
VA Sunshine Healthcare Network

Patient Falls

VISN 8 Patient Safety Center of Inquiry, Tampa

The VISN 8 Patient Safety Center of Inquiry (PSCI) mission is to support clinicians in providing safe patient care by designing and testing safety defenses related to the patient, provider, technology, and organization. Specifically, our goals are to (1) prevent injurious falls, minimize adverse events associated with hazardous wandering, and promote safe patient handling; (2) promote the safe use of technology; and (3) promote a culture of safety.  Our center includes a clinical program and a research translation approach to develop and test clinical innovations that can be exported throughout the VHA.

We were initially funded in 1999 and have been competitively refunded since then and have a track record of successfully translating patient safety research findings into practice. Our focus is Safe Patient Mobility, including injurious falls, hazardous wandering, and patient handling. Key clinical programs include an interdisciplinary comprehensive Falls Clinic and a Gait and Balance Clinic.  Referrals to the clinic are triaged to either a comprehensive assessment or a gait and balance assessment. The Falls Clinic provides a comprehensive assessment of fall risk factors in individuals identified at high risk for fall related injury. These individuals have a history of osteoporosis, prior fragility fracture and/or are on chronic warfarin therapy.  The Gait and Balance clinic provides individualized assessment and treatment of mobility for veterans who have sustained a fall or are at high risk for falls. In development, are clinical programs focused on the assessment of gait in veterans with specialty orthotic needs, amputees and those diagnosed with neurological diseases.

Significant infrastructure is in place, including a 30,000 sq ft building for Patient Safety Research, including eight laboratories (3-D Motion Analysis Lab, Biomechanics Lab, Patient Safety Engineering Lab, Body Weight Supported Treadmill Lab, Clinical Gait and Balance, Non-Invasive Skin Perfusion & Ischemia Detection Lab, Product Evaluation Lab, and Advanced Prosthetics Lab). The Office of Occupational Health and Environmental Safety has established a research lab and full time position on site to assist with Safe Patient Handling Initiatives, nationally within the VHA. Our staff has expertise in patient safety, has a track record of interdisciplinary collaboration, and is highly visible and productive.

Current Projects


Update of the NCPS Falls Toolkit for VHA

Plan: Update/revise the VA National Falls Toolkit with additional materials to move beyond setting up falls programs, to improving and sustaining them, and emphasizing injury prevention, rather than falls prevention.

Customized Fall Injury Reduction Program for VA Medical/Surgical Units

Plan: Invite interested VA facilities to participate in an organizational assessment of readiness to prevent injurious falls, identify gaps in practices, provide curriculum and assess for change in the units' readiness.

VA Live Falls Collaborative: Multifaceted Program to Reduce Risk for Fall Injury

Plan: Organize and deliver an 8 session webinar series to interested VA facilities nationwide to improve skills and knowledge base in the prevention of injurious falls.

Advancing Typology of Falls

Plan: develop and test a clinical decision-process to classify fall events that could improve fall prevention program evaluation related to preventable and nonpreventable falls.

Extracting Information from Text to Assess Adherence to Fall Prevention Guidelines

Plan: Complete a multi-site pilot study employing Information Extraction (IE) techniques applied to text documents from the EHR to determine if Veterans, who fall while hospitalized in the VHA, receive Guideline-based care post discharge.

Evidence Review and Current Practices on Use of Sitters

Plan: Develop evidence review, and describe current policies and best practices on use of sitters for fall prevention in inpatient areas.

Biannual Patient Safety/Falls Conference

Plan: Continue to organize biennially a 2-day patient safety conference on preventable adverse events related to mobility (falls, falls with injury, pressure ulcers) with national and international faculty.


Preventing Adverse Patient Events Using Safe Patient Handling Equipment

Plan: Refine SPH clinical tools to reduce patient safety risks associated with equipment technology and enhance the safety of patient handling through improved clinical practice in VA.

Safe Patient Handling Conferences

Plan: Conduct a 3-day conference to share the work done by PSCI and facilitate further research and collaboration in the area of SPH twice/year.



Best Practices on Missing Incidents for Informal and Formal Caregivers

Plan: Develop evidence based practice education modules for caregivers of persons with dementia providing strategies to rapidly locate a missing Veteran with dementia.

Developing New Technologies to Assist Dementia Caregivers

Plan: Identify how technology can support relatives providing in-home care giving to Veterans with dementia, what their unmet needs are and develop ideas for new technologies to meet those needs.

Hazardous Wandering/Missing Incidents Preconference

Plan: Organize a one day conference preceding the Patient Safety/Falls Conference and present the work in the areas of Wandering/Missing incidents to increase provider knowledge and skills, improve research opportunities and improve practice.

Previous Projects

Biomechanical Determination of Safe Footwear for Institutional Patients (2011-12)

Plan: Conduct laboratory evaluations of footwear and flooring for institutional patients as a function of static and dynamic coefficient of friciton for various flooring materials and conditions.

Tailored Medical Helmets for Specific Patient Populations and Co-Morbidities (2011-12)

Plan: Determine head impact characteristics as a function of patient type and fall conditions, to provide guidance for future design of helmets for head injury prevention.

VA Live Falls Collaborative: Multifaceted Program to Reduce Risk for Fall Injury in Acute Care (2011-12)

Plan: Organize a series of webinars for falls teams, to help integrate innovations in fall-injury reduction into acute care practices throughout VHA.

Data Extraction Protocol from CPRS for Falls and Fall-Related Injuries (2011-12)

Plan: Determine if an open source natural language processing program can reliably extract information from VistA to generate reports needed by Patient Safety Managers.

Feasibility and Safety Testing of a Combination Chair/Walker Mobility Device (2011-12)

Plan: Using qualitative and lab-based methods, we will explore the feasibility and safety of an alternate mobility device, a chair/walker combination.

Transforming Fall Management Practices Falls Conference (2012)

Held biyearly, this conference assembles faculty whose expertise is nationally known for shaping healthcare delivery systems and approaches to improve patient safety focusing on falls. The curriculum includes lessons learned, best practices, and cutting edge research findings related to safety for patients at risk for mobility-related adverse events. Click here to go to our conference page.

Social Marketing to Support Fall Prevention in Inpatient Psychiatry Units (2010-11)

The purpose of this project was to produce market segment specific recommendations for “selling” falls prevention in acute inpatient psychiatry, using social marketing methods. We conducted a total of 5 focus groups with different inpatient psychiatry providers (VA and non-VA) and have used the finding to guide the implementation efforts in falls projects. Manuscript Pending.

Fall Prevention Program Customized for Inpatient Psychiatry (2010-11)

The goal of this project was to modify and pilot test an “Organizational Readiness for Preventing Injurious Falls tool”, for inpatient psychiatry, to be used as a guide for strategic planning. The Tool was modified based on content expert review, and distributed to 5 VISN 8 sites. A site specific strategic plan was developed and implemented, as an example for other VA facilities to use.

Product: Injurious Fall Prevention Organizational Self-Assessment Questionnaire

The purpose of this questionnaire is to determine the implementation level of key fall injury program attributes within your hospital and  inpatient mental health units. By completing this survey, organizations seek information from administrative, advanced practice and direct care staff who currently practice in inpatient mental health  units.   

The objectives of this survey are to:

  1. Determine the level of implementation of fall and injury prevention attributes at organizational and unit level within your hospital and within VISN 8;
  2. Identify opportunities for fall injury program development and expansion as part of your strategic planning; and,
  3. Implement a learning community among your staff to assist with program implementation,
    spread and sustainability.
Click here to download the questionnaire

Unit Peer Leader Program (UPL) for Falls in Psychiatry Units (2010-11)

The goal of this project was to customize UPL role to inpatient psychiatry, as a mechanism to promote and sustain fall prevention programs. We developed a functional statement, criteria for selection and a Toolkit for UPL for Falls in psychiatry. Each VISN 8 site chose a UPL, which participated in a curriculum and implementation efforts. Click here to download the UPL Binder.

Medication Algorithm for Fall Risk in Outpatient Geriatric Psychiatry (2010-11) 

The goal of this project was to customize the existing Falls clinic algorithms for use by providers in geriatric psychiatry to raise awareness and decrease fall and injury risk related to medications. We reviewed/updated evidence on different medication classes and  developed specific algorithms for management of antidepressants, antipsychotics, benzodiazepines, antiepileptics/mood stabilizers, as well as summary algorithm that includes assessment of fall and injury risk. Manuscript Pending.

Customization of Hip Protector/Floor Mats/Low Beds in Psychiatric Settings (2010-11)

The goal of this project was to customize existing Hip Protector Toolkit and Guidance on use of edside mats for use in inpatient psychiatry, for high risk patients. We surveyed staff from all VISN 8 facilities, and conducted hip protector staff training in VISN 8to help with implementation. Majority of facilities reported stopping the use of hospital beds (now not allowed per recent VA Mental health guidance) unless patient is on 1:1 observation. Manuscript Pending.

Safe Patient Handoffs for Patients at Risk for Falls in Psychiatry (2010-11)

The goal of this program was to develop and test standardized hand-off communication tool for use in inpatient psychiatry that includes falls prevention/protection information.  We collected and reviewed all hand-off tools from VISN 8 and drafted a new tool that includes fall and injury risks assessment. It was reviewed and distributed to VISN 8 Clinical Experts for content validation. Click here to download.

The area of inpatient psychiatry presents unique challenges to organizations seeking to implement a safe patient handling (SPH) program. With existing equipment such as ceiling-mounted lifts providing opportunities for patients to harm themselves or others, and floor-based or sit-to-stand lifts proving incompatible with the platform beds present in psychiatric units, maintaining a work environment that reduces the caregiver's risk of
back and other musculoskeletal injury is difficult. Following a literature search and review on the subject of safe patient handling and psychiatry, a review of environmental design guidelines for inpatient psychiatric units, discussions with clinical staff and experts in this field, and a review of existing patient handling equipment specifically made to be used in a psychiatric unit, it was determined that there were two key areas of equipment development that would be required to meet the safe patient handling needs of this type of unit in and around the immediate vicinity of the patient's bed area. This report highlights the process by which a list of criteria was developed for the design of a height adjustable platform bed that meets the design guidelines for psychiatric units, and a list of criteria that articulates changes that could be made to existing SPH equipment design to meet the needs of this patient group and be compatible with the platform beds used in inpatient psychiatric units. Click here to download.

Ultra Wideband Radio Frequency Identification (UWB RFID) to Improve Fall Detection and Patient Care in Community Living Centers (CLCs) (2010-11)

The objective of this study was to determine whether UWB RFID technology may be used to detect falls in a clinical setting. This project examined the sensitivity and specificity of the technology to detect falls using 12 unique patients over the course of 100 days and fall precursors – the tortuosity or randomness in the patient’s path over time, and their total distance travelled. More research is needed before recommendations can be made about this technology application. Manuscript Pending.

Quantifying Fall Risk in Persons with Lower Extremity Amputation(s) (2010)

An educational module was designed by clinical researchers at the Tampa Patient Safety Center of Inquiry and the HSR&D/RR&D Center of Excellence: Maximizing Rehabilitation Outcomes for use by clinicians and researchers involved in the rehabilitation/study of persons with lower extremity amputation(s).

  • Information described in this module includes:
  • The prevalence and significance of falls in lower extremity (LE) amputees 
  • The identification of situations and circumstances most likely to cause or result in falls
  • The detailed description of selected functional performance measures to identify fall risk in this population
  • Identification of  interventions to minimize falls and fall related injury in this population

This module assists with the pursuit of excellence in delivering rehabilitative services to individuals with lower extremity amputation(s).
Please contact Valerie Kelleher at Valerie.Kelleher@va.gov or 813-558-3948 for a copy of this DVD.

Floor Mat Technology Guide (Excel)  (2010)

The goal of this guide is to provide information about currently available floor mat technology and provides vendor contact information. Click here to download the Guide.

Injurious Fall Prevention Assessment Tool (2009)

This survey, "Injurious Fall Prevention Organizational Self-Assessment," is a product from the VISN 8 Patient Safety Center and the IHI-RWJF Project "Reducing Serious Injuries in Medical Surgical Units," Project #57527. This survey was designed to help you determine the implementation level of key fall injury program attributes within your hospital and the inpatient unit that you work. After analysis of results, you can prioritize strategic planning to increase your organizational fall injury program scope and capacity. We hope this survey is helpful for you and ask that you notify us if you use this tool, and provide feedback if this product was helpful to your organization (Valerie Kelleher at Valerie.Kelleher@va.gov or phone her at 813-558-3948). Click here to download the Tool.

Hip Protector Toolkit (Word) (2009)

The goal of this toolkit is to promote the routine use of hip protectors in nursing homes by providing physicians, nurses, therapists and others with information and tools to assist them and overcome barriers to hip protector use. Click here to go to download the toolkit.

Prevention of Fall-Related Injuries: A Clinical Research Agenda 2009-2014 (.PDF)

This report details the collective consensus of falls experts to establish a research agenda for the prevention of injury due to falls for the next 5 years. We hope this research agenda will influence funding agencies to establish requests for research proposals to advance knowledge of falls prevention and management. Click here to download the research agenda.

Osteoporosis DVD (2007)

This educational program about osteoporosis is unique as it has a special focus on men, unlike current osteoporosis educational materials. This video is designed to teach men about osteoporosis risks, prevention and diagnosis.  This 13 minute video was prepared by the VISN 8 Patient Safety Center, funded by Merck & Co, Inc., and produced by the University of South Florida Health Media Center.

Click here to view the video 

This video is not closed captioned. Click here for a transcript.

Blood Thinners: Risk Factors Associated with Falling and What to Do When you Fall (.pdf)  (2007)

This brochure is an information guide for patients on blood thinners and the risks associated with falls. Click here to download the brochure.

James A. Haley Veterans Hospital: Reducing Severe Injury from Falls in Two Medical Surgical Units: Institute for Healthcare Improvement Collaborative Final Report July 1, 2006 to July 31, 2007 (.pdf)

This report summarizes the projects tests of change, lessons learned and outcomes for the initiative. The primary measurable goal of the project was to dramatically reduce injury from falls on medical-surgical units. Click here to download the report.

The Functional Balance Class Guide (Word) (2005)

This manual was devised to disseminate a successfully proven balance intervention strategy which was developed by the VISN 8 Patient Safety Center Falls Clinical Division. This treatment intervention consists of an 8-week Functional Balance Class with accompanying home exercise program. The class is led by a therapist (PT or KT), and convenes once per week. This intervention is targeted towards community-dwelling patients with balance and gait difficulties.  Click here to download the guide.

The Falls Toolkit (2004)

Many facilities are working to find ways to reduce the number of falls as well as the severity of the falls that do occur. In an effort to help facilities, we worked in conjunction with the National Center Patient Safety to create the Falls Toolkit.
The Falls Toolkit provides information on:

  • Designing a falls prevention and management program
  • Effective interventions for high-risk fall patients
  • Implementing hip protectors for fracture-risk fall patients
  • Educating patients, families and staff on falls and fall-injury prevention

The toolkit is available online at: http://www.patientsafety.gov/SafetyTopics/fallstoolkit