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VA National Center for Patient Safety


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Falls Toolkit


Fall prevention is an important and timely issue. As of March 2015, falls represented the number one category of root cause analyses submitted to the NCPS Patient Safety Information System, an internal, confidential, non-punitive reporting system.

Falls were the second highest category of sentinel events report
to the Joint Commission in 2014.Nurse helps patient on crutches in hospital.

NCPS staff members worked with the Patient Safety Center of Inquiry, Tampa, Fla.,
and others to develop the Falls Toolkit.

The Toolkit is designed to aid facilities in developing a comprehensive
falls prevention program.

We have made the Toolkit available for a number of years, begining in 2004.
The current editon, with updates and revisions, was posted in July 2014.

We appreciate feedback on this effort and the materials offered. If you would like to provide us with suggestions for improving the Toolkit or pass on stories as to how you used this information to improve the falls prevention program at your facility, please contact us:

Don't Miss Anything

The Toolkit consists of a wide variety of items, please ensure that you scroll to the bottom of this page to view all the resources we have provided.

Falls Notebook 

Title Documents
Contents Word


Instructions Word   
Background Word   
Falls Team Word   
Falls Policy Word   



Floor Mat Guide

Floor Mat Examples




Videos 1-2-3

Word  PDF 

Post Falls Huddle


Injurious Fall Prevention Organizational Self-Assessment Questionnaire

Fall Program Interventions Self-Assessment

The purpose of these questionnaires is to determine the implementation level of key fall injury program attributes within your hospital and inpatient units. By completing these surveys, organizations seek information from administrative, advanced practice and direct care staff who currently practice in inpatient units.

The objectives of this survey are to:

  • Determine the level of implementation of fall and injury prevention attributes at organizational and unit level within your hospital and within VISN 8
  • Identify opportunities for fall injury program development and expansion as part of your strategic planning
  • Implement a learning community among your staff to assist with program implementation,
    spread and sustainability

Once you have completed reviewing these tools and would like further guidance and support please contact either:

Julia Neily, RN, MS, MPH
Associate Director, VHA National Center for Patient Safety Field Office
White River Junction, VT
(802) 295-9363 ext. 6417


ACNSR/Associate Director VISN 8 Patient Safety Center of Inquiry, James A. Haley VAMC (151R)
HSR&D/RR&D Center of Innovation on Disability and  Rehabilitation Research VISN 8 (CIDRR8)
8900 Grand Oak Circle
Tampa, FL 33637-1022
Phone: 813-558-3912

Falls Reduction Podcasts

Pat Quigley and Julia Neily discuss various aspects of VA’s position on falls prevention in these two podcasts.

In the first one, two questions are answered:

  • Can Nurses alone effectively prevent falls?
  • Why has the VA focused primarily on protection from fall Injuries rather than falls? 
  • Listen to this podcast  

In the second, another two questions are addressed:

  • Can all falls be prevented?
  • If practice could be changed tomorrow, what four changes would you suggest?
  • Listen to this podcast 

Pat Quigley is Associate Director, VISN 8 Patient Safety Center of Inquiry, and leads many of the center’s fall and injury reduction efforts. Julia Neily is Associate Director, VA NCPS Field Office, and has been involved in many quality improvement initiatives. 

Both have authored or coauthored numerous articles on a wide range of patient safety issues, given conference presentations, and recently worked together to revise and update the Falls Toolkit.

Additional Information

The VISN 8 Patient Safety Center of Inquiry website offers a wide range of material on falls prevention.

Among the material is a brochure, Risk Factors Associated with Falling and What to Do When You Fall, provided as a guide for patients on blood thinners and the risks associated with falls.

The CDC “STEADI Program*† also provides an array of patient educational materials, which VA clinics can incorporate into their patient education programs. The material is in the public domain and some of it is available in multiple languages.

Implementation Guide for Fall Injury Reduction

Balance Assessment Handbook

Osteoporosis Overview

A 13-minute video on osteoporosis is also available and was prepared by the VISN 8 Patient Safety Center of Inquiry, funded by Merck & Co, Inc., and produced by the University of South Florida Health Media Center.

The approach is unique, as it has a special focus on men, unlike many osteoporosis educational materials. It’s designed to teach men about osteoporosis risks, prevention and diagnosis.

Enviromental Assessment



File Size: 95KB
Printed Size: 8.5 x 11 in
Pages: 1


File Size: 75KB
Printed Size: 11 x 17 in
Pages: 1


File Size: 7KB
Printed Size: 8.5 x 11 in
Pages: 1

Fall Risk Evaluations Handout 

File Size: 18KB
Printed Size: 8.5 X 11 in
Pages: 1

Timed Up and Go Test Handout 

File Size: 10KB
Printed Size: 3x5 in
Pages: 2

Morse Fall Scale Pocket Card 

File Size: 93KB
Printed Size: 11 x 17 in
Pages: 1

Hip Protectors Poster 

hip_pad_brochure.pdf (coming soon)
File Size: 88KB
Printed Size: 11 x 8.5 in
Pages: 2

Hip Pad Brochure 

File Size: 229KB
Printed Size: 11 x 8.5 in
Pages: 2

Fall Prevention at Home Brochure 

File Size: 1.6MB
Printed Size: 8.5 x 11 in
Pages: 1

Falls Toolkit Buttons 

Blood Thinners: Risk Factors Associated with Falling and What to Do When You Fall
File Size: 95KB
Printed Size: 11 x 8.5 in
Pages: 2

Anticoagulation Brochure thumbnail

Web Sites



Thank you for your continued commitment to falls prevention. If you have any questions or would like more information, contact us: 

*By clicking on these links, you will leave the Department of Veterans Affairs Web site.

VA does not endorse and is not responsible for the content of the linked Web site.