Combining Human Factors and Simulation Training to Reduce Falls
Event Type
Oral Presentations
TimeTuesday, April 132:40pm - 3:00pm EDT
LocationEducation and Simulation
DescriptionAbstract: A multifaceted approach to fall prevention program was implemented on one inpatient unit in an academic medical center. The multidisciplinary collaboration involved several interventions to achieve a strategic culture change that improved critical thinking skills focusing on patient fall prevention. Simulation was a innovative addition to the educational component and allowed learners to get hands-on practice in a realistic setting. Scenario-based training was conducted in a Simulation Center to teach critical thinking skills and build teamwork as part of a fall prevention program. The combination of interventions and Simulation Center training helped reduce total fall rate from 3.97 before intervention to 3.07 as well showing a reduction in falls with serious injury rate from 0.36 to zero (rate = falls per patient days x 1,000).

Two years prior to implementing interventions and simulation training, the nursing unit involved in this project had 63 patient falls (five of these falls resulted in serious injury). 77% of falls in one year occurred due to toileting needs or similar issues. There was a disconnect between risk factors and appropriate interventions to reduce the risk of a patient falling. While staff were aware of their individual roles and were working hard to keep patients from falling, there was a lack of awareness of how the team needed to work together to reduce fall risk. For example, in the case of ensuring fall prevention during toileting, a nurse aide may offer a patient the opportunity to toilet every two hours and think their task was complete. But a nurse would need to know if the patient hadn’t voided in six hours as an indication of clinical concern. The lack of shared awareness and differences in the culture of teamwork could result in nursing aides looking for the wrong cues when checking in with a patient for toileting. To help with this, the goal was to develop a culture of teamwork to achieve a deep understanding of how fall prevention measures integrate into the daily workflow for all staff.

A multidisciplinary, translational project began with unit-based observations from a Human Factors (HF) expert. A fall prevention committee was formed with front line workers (nurses, nurse aides, unit secretaries and leadership) guided by Process Improvement and HF Experts. The committee reviewed data for trends and brainstormed interventions then implemented them with their peers. Several interventions were trialed to address toileting needs of the patients:
• Potty Board and Night Buddy System: to increase frequency and quality of toileting opportunities for patients and improve documentation
• Storing Bedside Commode in Bathroom: to get the commode out of sight in attempt to discourage patients from getting up alone
• Pod Nursing Model: Nurses set up documentation stations to be close as possible to their assigned patients. Nurse proximity to a patient’s room improves response time to patient needs and bed alarms.
Interventions were modified as needed to make them successful for the front-line workers. In addition to physical interventions, training sessions were conducted in the hospital system’s Center for Simulation, Research and Patient Safety (Sim Center). Barriers and issues observed on the nursing unit were translated into the simulation environment to ensure that the simulated scenarios were realistic and customized to the needs of the unit. The unit director integrated front line nursing feedback on contributing factors for falls, and ideas for solutions.
Scenario Development: The simulation education facilitator gathered information about recent falls as well as the process improvement interventions that were being trialed and created four scenarios related to patient falls. These scenarios covered the topics of assessment and documentation, environmental hazards, competing patient priorities and post-fall interventions.
Simulation Training #1: All staff on the unit participated in this simulation training and provided valuable feedback during debriefing using a plus/delta approach. Every patient fall during this time was immediately reviewed by staff and the HF expert. The HF expert anecdotally noted a dramatic improvement in the critical thinking of the staff at each patient fall briefing. The staff were able to speak to the falls risk of the patients and the interventions that had been implemented. Failures were identified, and staff were dedicated to improving their patient safety scores.
Simulation Training #2: Approximately 10-11 months after the initial training, a second wave of simulation education was completed. The original concern was that the new staff needed to be brought up-to-speed on the unit’s expectation of falls prevention strategies (the unit experienced a turnover rate of approximately 50% prior to Simulation Training #2). However, it was identified through review of the initial training evaluation, that staff were not familiar or comfortable with lifting equipment. Training was adapted accordingly, both to meet new staff needs and to ensure that seasoned staff were getting new information.
For this second round of training, similar scenarios were utilized from the initial sessions but lifting equipment and techniques were integrated into the scenarios to improve staff usage of resources being provided for safe patient movement and handling. Scenarios were built to force the learners to get manikins out of bed with minimal assistance, this reinforced the need to use appropriate ergonomics and equipment and was realistic to the work environment of the staff when human resources were not available. The debriefing session mimicked the format of the initial training, but an additional 30 minutes of dedicated time was given to educate staff specifically on the use of the lifting equipment.
*Graphic of timeline illustrating all interventions

After simulation training the unit began to see a decrease in the amount of patient falls and an increase in the use of lifting equipment. In the 2-year period after the training, there were no falls with serious injury. There were fewer falls involving toileting as a contributing factor. There was an unprecedented 95-day fall-free streak. The total fall rates improved, showing a decrease from 3.97 before intervention to 3.07 after the second year of interventions and Sim Center training. Injuries improved as well showing a reduction in fall with serious injury rate from 0.36 to zero (rate = falls/patient days x 1,000).
The falls with serious injuries rate also improved with a decrease from 0.36 before intervention to zero. It is interesting to note that patient days increased by almost 1,000 per year in the two years of the intervention study. This increase was due in part to the unit moving to a new area. Before the implementation of the interventions, there were a total of five falls with serious injury. After the interventions, the total number falls with serious injuries fell to zero.
According to literature, the cost of a fall with serious injury is reported to be $13,316. Using this premise, the cost of five falls with serious injury would be $66,580.00 before the interventions and decreased to zero after the interventions. It is also worth noting, that the number of additional days of hospital stay for a fall with serious injury is around 6-12 days. The total number of additional hospitals days due to a fall with serious injury reduced from approximately 30-60 days down to zero days of additional days of hospital stay.

Table 1: Falls on Unit per Fiscal Year
* table summarizing data
Director of Human Factors Implementation
Human Factors Consultant
Simulation Lab Education Facilitator