Patient Safety / Quality

Protecting children by preventing falls

It’s a parent’s worst nightmare—fall that injures a beloved child. Pediatric falls can occur at home, at play, at school, and even in the hospital. Nurses can take the lead in helping to prevent falls and keep children safe.

The problem of falls

Falls are the leading cause of unintentional injury to children outside hospitals and a considerable concern during hospitalization. Fifty percent of falls occur in children younger than age 5. Children older than age 10, however, have the greatest risk of fall-related death and critical injury. Curiosity and development of motor skills are related to falls. Children at high risk for serious injury include preschoolers, children older than age 10 (twice as likely to fall as the total population), children with disabilities and minimal mobility, and children in wheelchairs, regardless of cognitive ability.

A “patient fall” is defined as an unplanned descent to the floor, either with or without patient injury. An “adjusted” fall is defined as a reported unintended event resulting in a person coming to rest on a floor or other lower level whether witnessed or not. A fall rate is measured as the total number of patient falls times 1,000 divided by total number of patient days.

Taking action

The Joint Commission and the Institute of Medicine have identified inpatient falls as a significant patient safety risk not only for adults but also for pediatric patients. The Joint Commission requires organizations to have a fall reduction program with interventions designed to reduce patient fall risk factors. Fall reduction strategies must be individualized, and programs must be evaluated to determine effectiveness. Staff as well as patients and their families must receive education on the fall reduction program.

Other efforts have focused on falls as well. Nurses have been transforming care through the Robert Wood Johnson Foundation and Institute for Healthcare Improvement initiatives supported by such efforts as Transforming Care at the Bedside. Several hospitals have focused attention on fall prevention programs, and the Agency for Health Care Research and Quality is supporting a Health Care Innovations Exchange that includes shared information on prevention.

Falls risk assessment

Pediatric fall cases differ from adult cases in that developmental stages are germane in analyzing pediatric fall data. Little research specifically related to pediatric falls and developmental stages has been conducted. Tools to assess risk of a fall for children are limited. Some children’s hospitals have tried to fill this gap by creating their own risk assessment tool or developing assessment tools with other institutions.


Adult tools such as the Morse Fall Scale seem inapplicable to children; however, several institutions (e.g., National Children’s Hospital) use a modified version of the Morse Fall Scale. Ann Hendrich developed the Hendrich II, adapting her earlier tool to include children. Other published pediatric fall risk assessment tools include the Graf PIF Scale, Humpty Dumpty Falls Scale, CHAMPS, and I’m Safe.

The Child Health Corporation of America (CHCA) sponsored a multisite study of 26 pediatric facilities that reviewed fall data over a 6-month period. Only children who fell were included in this study. The goal appeared to be prospective determination of characteristics related to risk of serious injury due to a fall after a fall had occurred. Injury rate for pediatric falls is determined by 1,000 patient days or 1,000 discharges. This is a considerably different approach from development of an instrument that validly identifies risk of a fall.

Despite assertions by some (primarily advocates of specific instruments), there are as yet no tools with published scientific and validated screening properties that adequately measure risk of a fall by a hospitalized child. Risk of a fall should be better determined before such a study is undertaken, and a “control” group of children who did not fall should have been included in the CHCA study. All current tools that “screen” for falls need improvement. One tool, the Humpty Dumpty Falls Scale, is reviewed below.

Humpty Dumpty Falls Scale

Validation of an instrument should be conducted outside the institution in which the instrument was developed. Research with the Humpty Dumpty Falls Scale (HDFS) was conducted outside its “development” hospital. A retrospective case-control study was conducted to assess its screening properties. HDFS scores were retrieved through occurrence reports and electronic medical records (EMRs). Expedited institutional review board approval was granted. Descriptive statistics were obtained for 74 falls (cases) in 2008 with 242 randomly selected controls (no falls) during the same year, N = 316 observations. The fall rate was 0.83 per 1,000 patient days.

Of the cases, 35% were not identified as high risk, using an HDFS score of 12+ as an indicator of high risk. The odds ratio (OR) of the association between a high risk score and a fall was 1.15 (CI; 0.39, 3.15, p > 0.76). Although sensitivity was 65%, HDFS specificity was only 26%. Sensitivity is defined as the degree to which the instrument correctly identifies persons at risk for the event in question. Specificity is defined as the degree to which the instrument correctly identifies persons screened not at risk for the event in question. In sum, the percentage of patients who fell was correctly classified as to their risk of a fall 65% of the time; however, 74% of patients who did not fall were “incorrectly” classified as at risk. Thus, the HDFS specificity is in question and in need of improvement.

Compared to adult patients, the pediatric patients who fell were alert, oriented, and ambulating, with only minor injuries reported. Developmental age, not gender, was identified as a risk factor for a fall. Using an HDFS score of 12 or greater (recommended on this tool), more than 70% of the control (nonfall) subjects were classified at high risk, which is an extraordinary high rate of false-positives. This HDFS result is much different from that reported at the institution in which the scale was developed.

Unfortunately, no reports were found of similar scientific evaluations (validations) of other tools when used outside the institutions in which these were developed. Interrater reliability of the use of these instruments also is needed.

At least two factors make the development of scientific assessment tools for pediatric falls difficult. First, falls, fortunately, are a low-incident event in children’s hospitals, and the development of valid and reliable screening tools for rare events is very difficult. Second, many of the institutions in which these tools are being developed and evaluated now have implemented fall prevention programs that may mitigate actual falls among those “truly” at risk for a fall, thereby leading to a spuriously large number of false-positives.

When this case-control study was conducted, pediatric patients at the children’s hospital had adult supervision, with either the family or staff in attendance. Since family-centered care is the care model for most children’s hospitals, further modification of the HDFS tool should consider increasing the number of parameters to include family attentiveness and behavioral actions.

While publications and presentations indicate that the HDFS captures some of the real risk of falling among hospitalized pediatric patients as shown by the OR at different scores or cut-points, additional research on and improvement of the HDFS tool and other fall-prevention tools are needed for effective and efficient screening. Far too many false-positives occur, and even the smaller number of false-negatives requires some “fix” to raise sensitivity above 0.80.

Preventing injuries

Until better screening tools are developed to assess risk of a fall, nurses should monitor pediatric patients frequently, complete a fall risk screen for documentation, strive for improvement of screens in practice, and document risk scores in the EMR, noting assessment, and implement preventive fall measures. These activities should include reassessment and notation of changes in physiologic, motor, sensory, or cognitive status. These activities by nurses might lead to critical improvements in fall prevention screening tools.

Identified “at-risk” patients could wear a sticker, ID band, or an appropriate symbol. If a patient is at high risk, staff and parents should adhere to institutional safety protocols, including careful placement of furniture in the room (such as the bed and assistive devices). Room objects, including the call light and telephone, should receive regular maintenance, and personal articles should be within easy reach. Cribs, high chairs, and infant seats should be used properly with side rails and protective devices (crib hood and gait belt).

Beds, cribs, and stretchers should be kept in the lowest, locked position. Rooms should have adequate lighting, room doors should be kept open, and the room environment should be uncluttered and free from obstacles. The standardized care plan should be individualized with notes for the pediatric patient at risk to wear nonslip footwear when up and to ask for assistance to the bathroom. Medication administration times should be evaluated and medication side effects frequently monitored. Parents should be aware of their ability to set appropriate behavioral and activity limits through education about fall risk factors, keeping in mind that parents tend to be more indulgent when their child is hospitalized.

Being vigilant

There is a need for staff awareness and vigilance with these “early” screening tools. At their current level of development, these tools should be perceived as an adjunct, not a substitute, for good nursing care, keeping in mind critical thinking skills and intuition. Nurses must assess pediatric patients’ risk of falls using appropriate understanding of information obtained from existing tools and good clinical observations, frequent monitoring of pediatric patients and their families, and implementation of falls prevention programs and strategies.

Patricia R. Messmer is Consultant for Nursing Education & Research at Miami Dade College, Miami, Florida. Arthur R. Williams is Professor and Chair, Department of Health Policy and Management, College of Public Health, University of South Florida, Tampa. Both authors previously were at Children’s Mercy Hospital and Clinics, Kansas City, Missouri, and wish to thank Michele M. Fix, BSN, RN, Children’s Mercy Hospital, Kansas City, Missouri, for her help during this project.

Selected references

Agency for Healthcare Research and Quality. Innovations Exchange: Bundle of interventions targeting high-risk patients with the aim of reducing falls and fall-related injuries on medical-surgical units. http://www.innovations.ahrq.gov/content.aspx?id=2611. Accessed May 18, 2012.

American Nurses Credentialing Center. Application Manual Magnet Recognition Program. Silver Spring, MD: American Nurses Credentialing Center; 2008.

Child Health Corporation of America Nursing Task Force Study. Pediatric falls: state of the science. Pediatr Nurs. 2009;35(4): 227-231.

Cooper CL, Nolt JD. Development of an evidence-based pediatric fall prevention program. J Nurs Care Qual 2007;22(2):107-112.

Graf E. Magnet children’s hospitals: leading knowledge development and quality standards for inpatient pediatric fall prevention program. J Pediatr Nurs. 2011;26(2):122-127.

Harvey K, Kramlich D, Chapman J, Blades E. Exploring and evaluating falls assessment instruments and injury risk indicators. J Nurs Manag. 2010;18:531-541.

Hendrich A, Bender P, Nyhuis A. Validation of Hendrich II Fall Risk Model. Appl Nurs Res. 2003;16(1):9-21.

Hill-Rodriguez D, Messmer PR, Williams PD, et al. The Humpty Dumpty Falls Scale: a case control study. J Spec Pediatr Nurs. 2009;14(1):22-32.

Kingston F, Bryant T, Speer K. Pediatric falls benchmarking collaborative. JONA. 2010;40(6):217-292.

Lavisso-Mourey R, Berwick D. Nurses transforming care: RWJ & IHI TCAB. Am J Nurs. 2010;109(11):3.

Messmer PR, Williams AR. Issues related to innovation: a case-control study of pediatric falls. American Academy of Nursing preconference, Washington, DC, November 11, 2010.

Morse J. Preventing Patient Falls. Thousand Oaks, CA: Sage Publications; 2007.

Neiman J, Rannie M, Thrasher J, Terry K, Kahn MG. Development and implementation of a comprehensive fall risk program. J Spec Pediatr Nurs. 2011;16(2):130-139.

Raffle A, Gray M. Screening: Evidence and Practice. Oxford: Oxford University Press; 2007.

Raszmus I. Falls in hospitalized children. Pediatr Nurs. 2006;32(6):568-572.

Stickland O. Use another institution to validate instruments [e-mail personal communication]. July 9, 2010

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