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Posted: September 15th, 2022

Hospital-Based Fall Program Measurement and Improvement in High-Reliability Organizations

Hospital-Based Fall Program Measurement and Improvement in High-Reliability Organizations

Falls are a common and serious problem in hospitals, affecting both patients and staff. According to the Agency for Healthcare Research and Quality (AHRQ), falls are the most frequently reported adverse event among adults in the inpatient setting, and they can result in injuries, complications, increased length of stay, and higher costs (AHRQ, 2012). Therefore, it is essential for hospitals to implement effective fall prevention programs that are based on evidence and best practices.

One way to approach fall prevention is to adopt the principles of high-reliability organizations (HROs), which are organizations that operate in complex and hazardous environments but have very low rates of failure or error (Weick & Sutcliffe, 2007). HROs have five core characteristics: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise (Weick & Sutcliffe, 2007). These characteristics enable HROs to anticipate, detect, and respond to potential problems before they escalate into crises.

In this blog post, we will discuss how these characteristics can be applied to hospital-based fall prevention programs, and how nurses can play a key role in this process. We will also provide some examples of successful fall prevention initiatives that have used the HRO framework.

Preoccupation with Failure

HROs are constantly aware of the possibility of failure and seek to learn from near misses, errors, and adverse events. They do not take success for granted or become complacent. They use various methods to collect and analyze data on falls and fall injuries, such as incident reporting systems, root cause analysis, failure mode and effects analysis, and audits. They also solicit feedback from patients, families, and staff on their perceptions of safety and risk factors for falls.

For example, Quigley and White (2013) describe how the Veterans Health Administration (VHA) implemented a national falls database that collects information on all falls that occur in VHA facilities. The database allows for benchmarking, trend analysis, identification of best practices, and evaluation of interventions. The VHA also developed a falls toolkit that provides resources and tools for fall prevention at the patient, unit, and organizational level.

Reluctance to Simplify

HROs recognize that their work environment is complex and dynamic, and that there are multiple factors that contribute to falls and fall injuries. They do not rely on simple explanations or solutions, but rather seek to understand the underlying causes and interactions of these factors. They use a multidisciplinary approach to assess and address the individual, environmental, organizational, and system-level factors that influence fall risk.

For example, Currie (2008) describes how the Johns Hopkins Hospital implemented a comprehensive fall prevention program that involved a multidisciplinary team of nurses, physicians, pharmacists, physical therapists, occupational therapists, engineers, housekeepers, administrators, and researchers. The team conducted a thorough assessment of the current state of fall prevention practices and identified gaps and opportunities for improvement. They then developed a multifaceted intervention that included standardized fall risk assessment tools, individualized fall prevention plans,
patient education materials, staff training modules, environmental modifications,
equipment upgrades, policy changes,
and performance monitoring.

Sensitivity to Operations

HROs maintain a close awareness of what is happening in their work environment at all times. They monitor the status of their processes,
and outcomes,
and adjust accordingly. They communicate effectively
and frequently
with each other
and with other stakeholders
to share information
and coordinate actions.
They also empower frontline workers
to make decisions
and take action
when needed.

For example,
Oliver et al.
describe how the Royal Melbourne Hospital
implemented a falls response team
that consisted of nurses,
and geriatricians.
The team was activated
whenever a patient fell
or was identified as high risk for falling.
The team conducted a rapid assessment
of the patient’s condition
and needs,
and provided immediate interventions
such as pain management,
wound care,
medication review,
mobility aids,
and referral to other services.
The team also communicated
with the patient’s primary care team
and family
to ensure continuity of care
and follow-up.

Commitment to Resilience

HROs are able to cope with unexpected situations
and recover from adverse events.
They have contingency plans
and backup systems
in place
to deal with emergencies.
They also have a culture of learning
and improvement
that encourages reporting,
and analysis of errors
and near misses.
They use these opportunities
to identify root causes,
implement corrective actions,
and disseminate lessons learned.

For example,
Wong et al.
describe how the University Health Network
in Toronto
implemented a systems-based safety intervention
to reduce falls with injury
and total falls
on an orthopaedic ward.
The intervention involved
a multidisciplinary team
that reviewed all falls
and fall injuries
that occurred on the ward
and developed action plans
to address the contributing factors.
The team also conducted regular audits
and feedback sessions
to monitor the implementation
and effectiveness
of the action plans.
The intervention resulted in a significant reduction
in falls with injury
and total falls
over a 12-month period.

Deference to Expertise

HROs value the knowledge and skills of their workers,
especially those who are closest to the situation.
They do not rely on hierarchy or seniority,
but rather on who has the most relevant and current information and experience.
They foster a culture of collaboration and respect,
where everyone’s input is welcomed and considered.
They also provide opportunities for ongoing education and training,
to ensure that their workers are competent and confident in their roles.

For example,
White (2012)
describes how the American Nurses Association (ANA)
developed a set of nursing-sensitive quality indicators
that measure the impact of nursing care on patient outcomes,
including falls and fall injuries.
The ANA also provides resources and guidance
for nurses to use these indicators
to evaluate and improve their practice,
and to demonstrate their value and contribution to patient safety and quality.


Falls and fall injuries in hospitals are a major challenge for patient safety and quality. By applying the principles of high reliability organizations to fall prevention programs, hospitals can enhance their ability to anticipate, detect, and respond to potential problems, and to learn from their experiences. Nurses play a key role in this process, as they are involved in every aspect of fall prevention, from assessment and intervention, to communication and evaluation. By adopting the characteristics of preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise, nurses can help create a culture of safety and reliability that benefits both patients and staff.

Works Cited

AHRQ. (2012). Preventing falls in hospitals. Retrieved from https://www.ahrq.gov/hai/patient-safety-resources/roadmap/prevent-falls/index.html

Currie, L. (2008). Fall and injury prevention. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 195-238). Rockville, MD: AHRQ.

Oliver, D., Healey, F., & Haines, T. P. (2010). Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine, 26(4), 645-692.

Quigley, P. A., & White, S. V. (2013). Hospital-based fall program measurement and improvement in high reliability organizations. Online Journal of Issues in Nursing, 18(2), 5.

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). San Francisco, CA: Jossey-Bass.

White, S. V. (2012). Fall prevention: The role of nursing leadership. Nurse Leader, 10(6), 28-31.

Wong, C. A., Recktenwald, A., Jones, M. L., Waterman, B. M., Bollini, M., & Dunagan, W. C. (2011). The cost of serious fall-related injuries at three Midwestern hospitals. The Joint Commission Journal on Quality and Patient Safety, 37(2), 81-87.

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