Organizational Fall Risk Factors

by Dr. Rein on January 16th, 2011
in Organizational Components

The root cause analysis of falls (i.e., root cause is the most fundamental reason a fall occurred) in hospitals and nursing homes due to 'organizational factors' consist mainly of:

Clinical Process Deficits

  • Risk assessments and reassessments not complete/inaccurate
  • Risk status not communicated among staff and patients/family members
  • Underreporting of falls by staff
  • Not documenting changes in conditions
  • Incomplete plans of care/follow-up
  • Staff underestimate/overestimate fall risk

Administrative Deficits

  • Lack of fall preventive policies, procedures and guidelines
  • Lack of staff education
  • Incomplete orientation of new staff
  • Inadequate staffing
  • Lack of resources (safety equipment/restraint alternatives)

In order to implement an effective fall prevention program, hospitals and nursing homes need to assess organizational factors contributing to falls.

Guide to Assessing Organizational Risk Factors

Step one:

Gather data and review potential areas of risk.

Previous institutional survey reports


Quality assurance/quality indicator reports


Occurrence/incident reports


Staff feedback


Patient and family feedback


Litigation claims

Step two:

Review facility practices

Review the charts of patients at fall risk/with falls (complete assessments, adequate care plans, targeted/updated interventions, etc.?).


Review facility procedures, protocols and guidelines related to fall prevention/restraint reduction activities (updated, do they match 'every day practice?).


Review staff education/orientation training activities related to fall prevention (current with procedures, protocols and guidelines?).

Step three:

Identify risk exposure (root cause analysis)

Based on steps 1 and 2, determine presence of clinical and administrative deficits or short comings.

Step four:

Assign a level of risk


During this part of the assessment, prioritize all problems identified that require corrective action (i.e., it's not possible or wise to fix everything at once).

Regardless of how a hospital or nursing home ultimately chooses to approach the creation of a risk-reduction program, the time and effort invested to assess risk exposure and develop a facility action plan is beneficial in reducing falls. Once organizational factors or deficits have been identified, there are a number of key ingredients in helping to reduce risk expose, these include:

A safety culture

  • A culture of safety permits staff to acknowledge the occurrence of error and encourages open and complete reporting of falls (i.e., placing emphasis on prevention, not punishment).

Operational approaches

  • Fall related protocols, procedures and guidelines must be current and include a step-by-step approach to help staff with fall prevention activities.


Educate all staff members about reasons for falls and interventions available to prevent falls. Follow-up education on specific problems identified from root cause analysis (both individual and aggregate falls) is also important.

  • Educate all staff members on protocols, procedures and guidelines related to fall prevention activities; ensure that staff are familiar with them. The use of protocols, procedures and guidelines help reinforce what should be done and when it should be done.
  • Educate patients/family members on fall risk and what steps the facility is taking to prevent falls from occurring.


  • Conduct regular audits or checks to monitor/discover clinical process and/or administrative deficits.
  • Any deficiencies observed can help to identify emerging trends and patterns that may contribute to falls.

1 comment

Comment from: Nancy [Visitor] Email
NancyThanks for the share!
09/30/11 @ 01:22

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