Preventing falls and minimizing injuries is difficult and complex.  Organizations many times have competing priorities which lead to fall prevention and protection from injury management being placed under one discipline such as nursing to address.  Fall prevention and protection from injury must be an organizational focus with all employees understanding their role and the impact that they can have in creating a culture of safety. (HRET 2016)
The Joint Commission's Sentinel Alert Event, Issue 55, released September 28, 2015 released their review and synthesis of current research \cite{alertpreventing}
"A considerable body of literature exists on falls prevention and reduction. Successful strategies include the use of a standardized assessment tool to identify fall and injury risk factors, assessing an individual patient's risks that may not have been captured through the tool, and interventions tailored to an individual patient's identified risks.  In addition, systematic reporting and analysis of falls incidents are important components of a falls prevention program. Historically, hospitals have tried to reduce falls -- and to some extent have succeeded -- but significant, sustained reduction has proven elusive."
Many succeed temporarily due to a "placebos" effect. Simply raising staff awareness will reduce falls for a short period of time.
Assessment tools have been instituted throughout most organizations as part of a fall prevention and protection from injury strategy.  Organizations should be cautious about utilization of tools that are internally designed without vetting through validation and interrater reliability processes.  There needs to be clarification about the role that tools have within the practice setting.  Tools used to triage for a fall are used to predict likelihood of an anticipated physiological fall and monitors fall risk (Degeleau 2012).  The tool provides the probability of an anticipated physiological fall but does not inform caregivers what to do about it (Morse 1989).  Assessment tools provide an assessment of the patient, such as gait, medication, mental status and other contributing factors.  These tools are used to reduce the probability of an anticipated physiological fall.  It is important that there is clarity about the tools being used and functionality to assure organizational performance \cite{degelau2012prevention}.
Analysis of falls with injury in the Sentinel Event database of The Joint Commission revealed the most common contributing factors pertain to: (Joint Commission 2015)
1. Inadequate assessment
2. Communication failures
3. Lack of resources, including staffing
4. Lack of adherence to protocols and safety practices
5. Inadequate staff orientation, knowledge, supervision, or skill mix
6. Deficiencies in the physical environment
7. Lack of leadership
As part of The Joint Commission Center for Transforming Healthcare Preventing Falls with Injury Project, seven U.S. hospitals entered into a pilot study using Robust Process Improvement© which incorporates tools from Lean Six Sigma to identify the root cause of falls and develop strategies to reduce them. The top contributing factors to a fall were: (HRET 2016)
1. Fall Risk Assessment Issues
2. Handoff Communication Issues
3. Toileting Issues
4. Call Light Issues
5. Education and Organizational Culture Issues
6. Medication Issues
A lack of congruence and organizational focus has caused, and continues to cause, preventable patient injury or death, and has increased the costs of care.  Closing the performance gap with an organizational focus will require leaders and their health systems to commit to specific actions by all disciplines throughout the organization.
A framework to consider is the "Knowledge-to-Action" model which provides the process steps required for knowledge inquiry and application into practice \cite{2009}.  Moving an organization forward to a precision performance requires an innovative approach with focused intent (Appendix A). 

Leadership Plan

Organizational Check:  What are the invisible rubber bands holding the organization back from advancing a culture of safety through a fall protection and injury prevention strategy?
Reducing fall injuries and deaths associated with falls is the ultimate outcome sought by leaders and their respective organizations.   While all leaders strive to transform culture and advance patient safety, reducing patient falls requires cutting the invisible rubber bands or biases of traditional actions and focus on the elevation of leadership and health systems' performance.
Leaders and their governing boards must: \cite{2004}
The following is the National Database of Nursing Quality Indicators (NDNQI) definitions which assist in standardization of the compiling of the data for comparative analysis \cite{metrics2012}.

Practice Plan

Organizational Check:  Do you have a process to routinely follow up after a fall to ensure that an injury was not subsequently identified?
Researchers agree that fall prevention and protection from injury strategies must acknowledge complexity and be multifocal, multicomponent in nature.
An effective practice plan needs to start with process steps before moving into application into the practice setting.  The following is a summation of the steps to be taken before design and implementation of actual program \cite{Miake_Lye_2013}.
  1. Determine the current state of fall program.  Look for standardization and points of where there is variation.
  2. Determine and understand the organizational context of the practice in fall prevention and protection from injury.  Have there been prior efforts to improve practice?  What lessons can be learned and barriers identified to address beforehand?
  3. Determine who prescribes and review medications.  Do those involved in medication regimes, including administration understand their roles in fall prevention and protection from injury \cite{Beasley_2009}?
  4. Determine how information about patient fall risk factors are communicated, documented and shared to assure appropriate actions and culture of safety.
  5. Determine current processes within specific departments or units.  Consider using such tools as process mapping to understand current practice and where actions could or should be happening for fall prevention and protection from injury.  While process mapping is time-consuming, examining each step can give critical insight into not only how particular care processes are being carried out, but can lead to further discussion on how they should be carried out.
  6. Determine how to integrate practice changes in current workflows and rituals within the care settings. 
  7. Determine the current state of staff knowledge and understanding of fall assessment, prevention and protection from injury.  Exploring possible biases about conducting risk assessments, interventions and perspectives about falls. 
Factors associated with Patient Falls can be divided into four areas of influence.  The following table outlines the factors to assist organizations to develop interventions and practice actions after assessing their current processes \cite{morgan1985hospital}.