DETECT Falls: Tailoring Interventions for Patient Safety

Falls are a serious patient safety issue affecting Iowans everyday. In 2016 in Iowa alone, there were nearly 88,000 falls-related emergency department visits that resulted in 8,300 hospitalizations. Between 2007 and 2016, there was a 56 percent increase in the number of falls-related deaths. We know that most falls are preventable. To protect patient safety and patient lives, we must work together to prevent falls in all care settings. Participating in this pre-recorded webinar course holds many benefits. This course, in its entirety, will take an estimated 5 hours and 59 minutes to complete, but is set up in sessions and does not have to be completed all at once.

This pre-recorded webinar course was developed in support of the Hospital Improvement Innovation Network (HIIN) in 2018.

Transcripts are available upon request. 

The Compass Hospital Improvement Innovation Network (HIIN) is supported by contract number HHSM 500 2016 00070C from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.

Target Audience

Hospitals and long-term care facilities

Course summary
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The goal of the DETECT Falls: Tailoring Interventions for Patient Safety course is to establish enhanced community approaches to fall preventions by connecting hospitals, long-term care facilities, patients and caregivers.


Presenting the Case

Introduction of the project and DETECT Falls philosophy

  • Review the DETECT Falls framework
  • Outline the project
  • Discuss next steps


Assembling the Team

Hospitals and long-term care facilities create a community team

  • Identify team-based approaches to falls prevention
    • Internal facility teams
    • Community-based team
  • Identify aligned strategies for fall prevention
  • Explore opportunities for shared care planning
  • Outline DETECT Falls Team interaction


Gathering the Clues

Understanding and using a fall risk assessment

  • Detail the tool and reviewed the evidence behind Fall TIPS
  • Explain the importance of using a valid fall risk assessment
  • Discuss use of the Morse Fall Scale in long term care facilities
  • Review the Fall Prevention Knowledge Test


Following the Leads

Implement Fall TIPS (Tailored Interventions for Patient Safety)

  • Discuss components of an evidence-based fall prevention program
  • Examine Fall TIPS as a model
  • Discuss methods to train staff to use the Morse Fall Scale to conduct a valid fall risk assessment
    • Interventions, implementing the plan, audits
    • Introduce Project RedCap


Digging Deeper

Post-fall management and auditing

  • Discuss Post-Fall Management strategy
    • What are you currently doing?
    • How can you improve?
  • Review Fall TIPS Auditing Process


Expanding the Search

Community care transitions and community resources

  • Examine community care transitions – from acute to post-acute to home and beyond
    • Warm hand-offs and sharing of information
    • Opportunities for aligned assessments and interventions
  • Discuss community resources and patient self-management supports


Closing the Case

Project wrap-up and success sharing

  • Discuss successes and barriers
  • Review resources for support
  • Next Steps

Kate Carpenter, BHA, CPHQ, RT(R)(M)(CT), Previous Clinical Quality Consultant, Current Director of Hospital Quality Initiatives, Iowa Healthcare Collaborative

Kate Carpenter is director of hospital quality initiatives at Iowa Healthcare Collaborative. She holds a bachelor’s degree in healthcare administration and is a NAHQ Certified Professional in Healthcare Quality. Carpenter leads the Compass Hospital Improvement and Innovation Network and leads the design of innovative quality, patient safety and performance improvement projects to drive sustainable and transformational improvement efforts across the care continuum. She serves as the co-lead to the PfP Readmissions Affinity Group and on the Iowa Care Coordination Statewide Strategy committee. Carpenter has 12 years of clinical experience in the medical imaging field and holds board certifications in general radiography, mammography and computed tomography.


Kady Reese, MPH, CPHQ, Previous Program Lead of Statewide Strategies, Iowa Healthcare Collaborative

Kady Reese served as the director of patient-centered design with the Iowa Healthcare Collaborative. In this role, Reese directed statewide strategic operations aimed at development of cross-collaborative and multi-disciplinary standards for population health to address priority health issues and disease states. She offered an array of experience across the healthcare continuum, including home health, primary and urgent care practice, healthcare administration and quality reporting. She holds a master’s degree in public health from Benedictine University, as well as certificates in health management and policy and health education and promotion. She is a national champion for Person and Family Engagement with CMS as part of the Partnership for Patients and the Transforming Clinical Practice Initiatives. Reese is an ardent advocate for public and population health.


Patrica Dykes, PhD, MA, RN, FAAN, FAACMI, Senior Nurse Scientist, Program Director for Research at Brigham and Women’s Hospital Center for Patient Safety Research and Practice, Associate Professor of Medicine at Harvard Medical School

Dr. Patricia Dykes, Associate Professor of Medicine at Harvard Medical School and Senior Nurse Scientist, Program Director for Research at Brigham and Women’s Hospital Center for Patient Safety Research and Practice received her bachelor‘s degree in nursing from Fairfield University, a master’s degree in nursing from New York University and a doctorate in nursing informatics from Columbia University. Her interests are in quality and safety of care and adverse event prevention, especially as it relates to hospitalized inpatients. As principal investigator of an interdisciplinary research project funded by Robert Wood Johnson Foundation, Dr. Dykes led a team that established a link between a standardized fall risk scale with individualized tailored interventions to prevent patient falls in hospitals. Dykes and her team developed Fall TIPS, a decision-support and communication intervention for use by the care team, patients and family members to prevent patient falls. Over a six-month randomized-controlled trial, the use of Fall TIPS reduced in-hospital falls by 25%.


Srijesa Khasnabish, BA, Research Assistant

Srijesa Khasnabish is a research assistant working with Dr. Patricia Dykes on the Generalizabliity and Spread of an Evidence-Based Fall Prevention Toolkit: Fall TIPS. This is a multisite project in collaboration with New York-Presbyterian and Montefiore Healthcare systems to spread the Fall TIPS program. She has worked on the qualitative aspect of developing the Fall Prevention toolkit, through interviewing patients and staff through the Partners Healthcare system. She has assisted Dr. Dykes with numerous webinars, presentations, and workshops interested in implementing Fall TIPS across the country. She is currently a medical student at the New York Institute of Technology College of Osteopathic Medicine.

No continuing education is provided for this course. The user will receive a certificate of completion upon completing the course.

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