title: A Falls Wheel in a Large Academic Medical Center: An Intervention to Reduce Patient Falls With Harm.
abstract: This article presents an evaluation of a multifaceted fall prevention initiative. The main element of this initiative was the creation and implementation of a Falls Wheel--a visual communication tool of a patient's fall injury risk for all care team members placed on every patient door throughout the health system. The Falls Wheel allows for patient categorization along two dimensions simultaneously: risk of fall and risk of injury from a fall. During the yearlong implementation, the rate of falls with harm dropped by almost 50%. A process audit revealed that there was high fidelity to the intervention components, including displaying the wheel correctly 95% of the time, and the Falls Wheel was updated to match the risk level in the electronic health record 70% of the time. The goal of this article was to share the experience of one health system and encourage others to adopt and rigorously test the Falls Wheel. Replication and extension of this program at other hospitals and health systems will enable staff and empower patients to reduce falls with harm and their unintended consequences.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Hefner
authors.forename: Ann Scheck
authors.initials: AS
authors.lastname: McAlearney
authors.forename: Jerry
authors.initials: J
authors.lastname: Mansfield
authors.forename: Amy M
authors.initials: AM
authors.lastname: Knupp
authors.forename: Susan D
authors.initials: SD
authors.lastname: Moffatt-Bruce
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration* / Q000706:statistics & numerical data; D000058:Accidental Falls / Q000517:prevention & control* / Q000706:statistics & numerical data; D057286:Electronic Health Records; D006801:Humans; D017063:Outcome Assessment, Health Care; D018570:Risk Assessment; D012307:Risk Factors; D017751:Safety Management / Q000458:organization & administration; D014947:Wounds and Injuries / Q000517:prevention & control*