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Slips, Trips and Falls: Risks for Older Adults and Prevention Strategies for Care Settings

Blog Post | Slips, Trips and Falls: Risks for Older Adults and Prevention Strategies for Care Settings

Slips, trips and falls are a leading cause of injuries among older adults, especially those in care homes or hospitals. Falls Prevention is necessary to stop increase in cases especially in care settings.

These incidents can severely impact mobility, independence, and quality of life.

However, many factors that contribute to falls are preventable through risk assessment, environmental adaptations, assistive equipment, staff training, and exercise programs.

A multi-faceted approach involving various stakeholders is crucial for safeguarding vulnerable residents.

This article explains slips, trips, and falls and highlights major fall prevention techniques within care settings.

We also delve into NICE guidelines and the responsibilities of healthcare workers, especially in protecting older people who are vulnerable.

Table of contents

Defining slips, trips and falls, common slip hazards to look for, common trip hazards to remove, common fall hazards to address, risk factors for falls in older adults, why falls are dangerous for older people, checks on fall risk assessments, home adaptations to prevent falls, home environment assessment and modification, environmental design in institutional settings to prevent falls, mobility aids and assistance in falls prevention, falls analysis: medical and medication optimisation, assistive equipment and mobility aids in falls prevention, physical therapy and exercise interventions, protective equipment against slips, trips and falls, training care staff on fall prevention, fall prevention: creating safe care facility environments, post-fall assessment and intervention, preventing falls: following the recommendations from nice, in conclusion, recent posts.

Slips occur when traction is lost between the footwear and the walking surface, causing imbalance. This often results from wet, greasy or icy flooring.

Trips happen when legs hit an object, obstruction, or uneven surface, disrupting the normal walking motion and causing a loss of balance.

Falls result when the body loses balance completely after slipping or tripping and is unable to arrest descent. Falling to the floor or ground often leads to injury.

Check out our face to face Fall Prevention Training and learn about the course content.

Statistics on Slips, Trips and Falls

Slips, trips and falls lead to high rates of hospitalisation, disability, loss of independence, and reduced quality of life among older adults.

Key falls statistics include:

• Falls are the leading cause of fatal and non-fatal injuries for those aged 65+, responsible for over 36,000 elder deaths annually in the UK.
• Over 435,000 people aged 65+ visit the UK hospitals each year due to falls. This equates to about 1,200 admissions per day.
• Around 24% of UK care home residents fall each year. Falls account for 40% of all deaths from injury in care facilities.
• The cost to the NHS from falls by seniors exceeds £2.3 billion per year and is projected to surpass £3.6 billion by 2030.

Falls are a big problem that can cause a lot of harm. This is why it is important to take steps to prevent falls, especially in places where people are being cared for.

Slips occur when feet slip out from under someone on a slippery surface. Things that often cause slippery spots include:

• Water, grease or food spills on floors.
• Soap residue left on bathroom floors.
• Snow, water or mud tracked in from outdoors.
• Loose rugs, bathmats or other items that can slide.
• Waxed or shiny finished floors that are very slick.

All these slick surfaces can lead to dangerous slips.

But cleaning up spills right away, removing loose rugs and using slip-resistant floor finishes can help avoid slips.

Tripping happens when legs hit an object causing someone to lose balance and fall. Some examples of tripping dangers include:

• Electrical or oxygen tubes crossing pathways.
• Bunched up carpet edges or uneven surfaces.
• Items left in halls or doorways like carts or boxes.
• Thresholds or level changes between rooms or flooring.
• Poor lighting so people cannot see hazards.

Keeping walkways perfectly clear, adding nightlights in rooms and hallways, and fixing uneven floors reduces tripping risks.

Sometimes the issue is not slipping or tripping but losing balance.

Things that can lead to falls include:

• Using ladders, step stools or chairs to reach high places.
• Climbing on beds, sofas or other furniture.
• Bending over without holding on to something sturdy.
• Reaching too far while sitting in chairs or wheelchairs.
• Standing up too quickly and getting dizzy.
• Using mobility aids that do not fit right.

Staying mindful, moving carefully, and using grab bars and proper steps can help avoid dangerous loss of balance.

Many older people are at risk of falling for several reasons:

• Weak muscles, difficulty walking, and balance problems due to aging, stroke, or arthritis.
• Memory and thinking issues from dementia, confusion, or certain medications.
• Declining eyesight because of conditions like macular degeneration 1 , glaucoma 2 , or cataracts 3 .
• Heart problems like low blood pressure, fainting, or irregular heartbeats.
• Brain conditions such as Parkinson’s disease 4 , nerve problems, or seizures.
• Fragile bones due to osteoporosis 5 , which can make injuries worse.
• Long-term health conditions and medications that cause dizziness or the need for frequent bathroom visits.
• Hazards in the home or care facilities that can lead to falls.

Identifying things/elements that can be adjusted enables more specific fall prevention strategies.

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As people get older, falls can be very risky because:

• Bones become weaker and break more easily, like hips and wrists.
• Older individuals often take more medicines, which can sometimes cause dizziness or tiredness, increasing the risk of falls.
• Fading eyesight and hearing can make it more challenging for seniors to notice potential dangers.
• Slower reflexes mean they can’t react as quickly to regain balance when they start to fall.
• Joint pain or stiffness, particularly in knees or hips, can affect their balance.

Falls can lead to various problems for older people, such as:

• Broken hips, wrists, head injuries, bruises, and sprains.
• The need for hospitalisation, surgeries, infections, and prolonged bed rest, which weakens muscles.
• A loss of confidence, worries about falling, avoiding certain activities, and becoming more isolated.
• Health issues like blood clots, pneumonia, and pressure sores due to immobility.
• Having to use walking aids, wheelchairs, or needing more care.
• Reduced ability to do everyday tasks like getting dressed, bathing, and using the toilet.
• A higher chance of having to move into a care facility.
• A greater risk of passing away within a year after a fall.

Preventing falls is crucial for older people to have a better life and slow down their decline.

The first step is formally evaluating individual risk factors:

• Medical history – Chronic conditions, medications, acute illness
• Physical exam – Gait 6 and balance deficits, weakness, vitals, vision/hearing
• Functional evaluation – Ability with activities of daily living
• Environmental assessment – Home safety evaluation
• Psychosocial factors – Fear of falling, depression, loneliness
• Laboratory data – Electrolyte imbalances, anemia, vitamin D

Standardised tools help quantify risk and guide interventions. Risk should be rechecked regularly and after any falls to adjust plans.

Simple home modifications can significantly reduce hazards:

• Improve lighting throughout, especially at entrances, stairs, and bathrooms. Install nightlights.
• Add grab bars in bathrooms near toilet and in tub/shower. Use shower seats.
• Apply reflective tape to stairs to highlight edges. Ensure steps have even rise/run and slip-resistant surfaces.
• Remove loose rugs and cords crossing walkways. Consider changing to low-pile carpets.
• Rearrange furnishings to create wide clear pathways. Remove clutter creating tripping risks.
• Use chairs with armrests that make rising easier. Ensure proper height beds and toilets.
• Have phones and call buttons accessible from bed and other frequent locations.

A home occupational therapy evaluation can identify needed adaptations.

A home assessment identifies hazards to eliminate.

The goal is to identify potential safety hazards and make necessary modifications to ensure the facility or home is safe and suitable for the needs of the individual.

Home Environmental Assessment involves checking for things like:

• tripping hazards,
• adequate lighting,
• handrails, and
• other factors that can impact a person’s safety and mobility within their home/facility.

1. Flooring

• Ensure carpeting is low-pile, non-slip, and secured firmly with no lifted edges.
• Remove small loose rugs or use non-slip backing.
• Repair cracked, uneven surfaces that could trip users.
• Keep highly glossy floors free of water, debris, and clutter.

2. Lighting

• Provide adequate illumination in all rooms, stairs, and entrances.
• Ensure lighting switches are easy to access from entrances.
• Use maximum wattage bulbs allowed in fixtures.
• Install nightlights to illuminate paths between bedroom, bathroom, and stairs.
• Confirm railings are tightly secured on both sides of stairs.
• Apply bright reflective tape to top and bottom stairs to highlight edges.
• Eliminate raised lips between floors and landings.
• Keep stairs free of objects. Never store items temporarily on stairs.
• Remove coil or tape cords and wires out of walkways.
• Secure loose carpets and matts.
• Remove furniture clutter blocking paths.
• Use cordless phones to avoid rushing for phone.
• Mount grab bars in bathrooms near toilet and shower entrance.
• Use shower chairs and tub transfer seats.

5. Entryways

• Ensure outdoor steps have railings and adequate lighting.
• Keep walkways even and clear of debris, snow, and ice.
• Place mats firmly so they do not shift.
• Position bed for easy access from both sides.
• Install bedside lighting within easy reach.
• Have telephone and call button close but not hazardous.
• Avoid bedroom clutter than can be tripping hazards.

8. Kitchen  

• Store commonly used items within easy reach.
• Provide stable step stools for hard-to-reach cabinets.
• Avoid use of chairs or surfaces not meant as steps.

Personalised home hazard assessments help find risks that can be fixed.

Get Certified – Complete Our Falls Prevention Online Course – CPD Approved

Modifications to care settings like hospitals and nursing homes include:

• Color code unique paths through facilities using distinct flooring patterns, wall colours or themes.
• Provide adequate directional signage and room numbers for clear wayfinding.
• Eliminate changes in flooring height between rooms or hallways.
• Keep hallways uncluttered with ample seating alcoves for rest breaks. 
• Use contrasting colors on toilet seats, door frames, bed rails, stair edges, and grab bars for easier recognition. 
• Install non-slip tread on stairs. Improve lighting over stairs and entrances.
• Have ample means of summoning assistance like call buttons, phones, audible alarms.
• Use pressure sensor mats that alarm if someone tries to leave beds or chairs unattended.

Environmental design changes promote safe mobility for patients and residents.

Mobility aids and assistance are tools and support that help people move safely, reducing the risk of slips, trips, and falls.

This includes items like canes, walkers, wheelchairs, and grab bars, as well as help from caregivers or staff to prevent accidents.

Mobility aids provide needed support while maintaining independence. Here are some things to keep in mind when using mobility aids:

• Fit individuals with appropriate assistive devices like canes, walkers, or wheelchairs and provide training until proficient in use.
• Check regularly that aids are in good repair, fitted properly, and used as directed.
• Remind users to lock brakes before standing up from chairs and wheelchairs.
• Encourage use of aids at first sign of unsteadiness rather than waiting until at higher fall risk.
• Provide standby assistance or hands-on support only as needed for safety during walking or transfers. Avoid over-assisting.

Matching aids to user and task enables mobility with confidence.

Evidence-based medicine adjustments include:

• Reviewing all medicines for types linked to dizziness or syncope. Lowering psychoactive drug doses if possible.
• Providing vitamin D supplementation to improve muscle strength and bone density.
• Evaluating and treating vision and hearing issues to optimize input affecting balance.
• Managing cardiovascular disorders, such as carotid stenosis or arrhythmias, that increase fainting risk.
• Conducting medication reconciliation to eliminate unnecessary medications.
• Treating arthritis, diabetes, Osteoporosis, and other conditions contributing to pain, neuropathy and falls.

Therapeutic remedies reduce intrinsic fall risks.

Devices provide needed stability and support:

• Canes or walkers – Improve balance while walking.
• Grab bars – Assist with transitions like standing up or getting in/out of bath.
• Reachers – Allow grasping items without over-extension.
• Proper footwear – Shoes with arch support, cushioning and non-slip soles. Avoid socks or smooth floors.
• Assistive tech – Sensors that alert carers to attempts to rise unsupervised. Personal alarms summon help after a fall.

Ensuring aids suit user needs and environment promotes safe mobility.

Research confirms properly prescribed exercise reduces fall rates and severity through improving strength, flexibility, balance and stability.

Recommended programs involves:

• Muscle strengthening – Legs, core, hips, shoulders.
• Balance training – Heel-to-toe walking, Tai Chi, reducing base of support.
• Gait and mobility practice – Walking aids, changing direction, uneven surfaces.
• Stretching – Yoga, Pilates, maximizing joint flexibility.
• Endurance – Low-impact cardio like recumbent bikes.

A physical or occupational therapist can tailor exercise regimens to individual abilities. Consistency is key. Even chair exercises improve mobility.

Balance, Strength and Gait Training

Balance, Strength, and Gait Training are exercises that help people in care settings (including seniors) become steadier, stronger, and better at walking.

These exercises reduce the risk of residents slipping, tripping, or falling by improving their ability to stay balanced and react quickly to avoid accidents.

Targeted exercise programs improve stability, but always ensure that it is done by a professional.

Some of the things to consider for the training are:

• Tailor flexibility, balance, coordination, and leg strengthening exercises to individual’s baseline abilities. Focus on core and lower body.
• Add balance challenges like standing on one foot, walking heel to toe, and proprioceptive exercises.
• Use weighted vests and resistance bands to improve muscle strength needed for support and recovery.
• Practice standing up and sitting down frequently with or without use of upper limbs.
• Re-train proper gait mechanics through walkway marking, mirrors, and feedback on posture and stride length.
• Consider referral for physical or occupational therapy evaluation to develop personalised exercise programs if needed.

Regular exercise helps prevent falls.

Protective accessories cushion against impact:

• Wear sturdy shoes with non-slip soles that fit well. Avoid walking in socks or smooth soles.
• Use shatter-resistant lenses and side shields on eyewear.
• Protect joints with wrist guards, helmets, hip protectors, and knee pads.
• Place cushioning floor mats or pads near beds, chairs, and showers.
• Use trapeze handles or lifts above beds for those at a high risk of falling.
• Wear alarm devices that call for help after a fall.

Additional equipment makes things safer.

Equipping staff helps sustain safety:

• Education on identifying fall risks and prevention techniques.
• Training on proper use of mobility equipment – walkers, wheelchairs, lifts.
• Skills practice providing mobility assistance like transfers.
• Protocols for frequent safety reminders and risk prompt communication across caregiver shift changes.
• Monitoring program participation and outcomes to fine-tune training.

Standardizing competencies ensures consistent fall prevention application.

Hospitals and care homes can implement building-wide safeguards like:

• Keeping floors clean, dry, even, and slip-resistant. Promptly wiping spills. Using warning signs for wet floors.
• Removing trip hazards in hallways and rooms. Securing mats, cords, and carpet edges.
• Conducting routine safety checks of furnishings, fixtures, rails, call systems. Repairing hazards promptly.
• Ensuring adequate lighting throughout facility and grounds, especially at changes in floor height. Installing night lights.
• Providing handrails on both sides of corridors. Painting contrasting colors on stairs.
• Furnishing activity rooms and resident lounges with stable armchairs and seating that is easy to rise from.
• Using patient identifiers like wristbands or photos before assisting mobility or administering medications to prevent treatment errors that could cause dizziness.

Environmental adjustments protect entire populations long-term.

Making Kitchen and Dining Areas Safer

Kitchens have lots of risks like spills, especially in care homes. Important safety steps are:

• Cleaning up all spills quickly to avoid slips.
• Allowing only staff in the kitchen to avoid burns.
• Keeping hot food and liquid out of reach of residents.
• Having sturdy armless chairs with grab bars for easy rising.
• Providing plates and cups with special grips and edges if needed.

Eating areas must have good chair supports and slip-resistant floors.

Fall Preventive Measures- Improving Bathroom Safety

Bathrooms have lots of slick surfaces. Helpful ideas include:

• Putting out warning signs when floors are wet.
• Adding extra grab bars, shower seats and rubber mats.
• Always using non-slip bathmats with rubber backing.
• Providing stairs or bath lifts if tubs are hard to enter.
• Adding higher toilets and using toilet frames with arms.
• Checking water temperature to avoid burns with a thermometer and recording it.

Handrails, shower grab bars, floor mats and raised toilets or toilet seats reduce the chance of sliding in bathrooms.

Enhancing Bedroom Safety for fall prevention

Bedrooms have their own risks to avoid:

• Keeping floor areas around beds and dressers free of objects.
• Providing lamps and nightlights that are easy to reach from bed.
• Making sure call bells for help are always close by.
• Adding grab bars, handles or steps for those with tall beds.
• Using monitors or sensors that alert staff if someone tries to leave bed.

Bedroom hazards can be lessened with lighting, cleared spaces, easy access to help and steps for high beds.

Improving Overall Safety

Some general things that help lower risks everywhere include:

• Regular cleaning of eyeglasses for the clearest vision.
• Providing mobility aids like canes, walkers and wheelchairs fitted to each person and checking they are in good shape.
• Putting handrails on both sides of all stairs and hallways.
• Adding good lighting everywhere indoors and outside.
• Ensuring proper indoor and outdoor lighting.
• Keeping extension cords and power strips out of pathways.
• Using chairs with armrests that make rising easier.
• Having activities to build strength, balance and coordination

Frequent checks ensure the environment helps prevent tumbles.

If care and hospital workers all join in and follow proven steps to prevent falls, the risk can be significantly lowered, helping even frail adults stay strong.

A careful and forward-looking strategy that concentrates on keeping residents safe while moving increases their confidence and helps them stay active.

A post-fall assessment and intervention is the process that follows a fall. It involves examining why the fall occurred, assessing any injuries or changes in the person’s condition, and taking steps to prevent future falls.

This may include adjusting the person’s care plan, making changes to the environment, or providing additional support to enhance their safety and well-being.

What should you do after a fall?

After a fall, key responses include:

• Stay with the person and provide comfort while waiting for help.
• Give first aid if there are any injuries or bleeding.
• Check the person’s nervous system and blood circulation and keep an eye on their vital signs for confusion or delayed reactions.
• Discuss the situation and what caused the fall with the staff in a post-fall meeting.
• Update risk assessments and care plans to address any new issues.
• Increase supervision or monitoring if the person is confused, in pain, or agitated.
• Arrange for tests like X-rays if there might be fractures, head injuries, or internal bleeding based on how severe the symptoms are.
• Help the person overcome their fear of falling by offering counseling and teaching them how to move safely.

Organisations can lower the chances of falls and help those at risk stay mobile and independent by using proven methods and keeping the environment safe.

Creating a culture of being careful, talking well, and taking care of people helps them stay healthy and live longer.

The National Institute for Health and Care Excellence (NICE) publishes advice on preventing falls, especially for older adults. These guidelines help health and care providers promote safer, healthier ageing – reducing the risk of falls and enhancing independence.

The NICE guidelines for fall prevention include:

• assessing fall risks,
• medical reviews,
• exercise programs,
• home safety checks,
• practical support, and
• ongoing risk monitoring.

So, let’s examine each aspects of the NICE guidelines to help prevent fall within the care settings.

Assessing Fall Risks

NICE advises checking all older people for fall risks. Ask about any falls in the past year. Look for issues like:

• Unsteady walking or needing help to move around.
• Falling more than once.
• Feeling dizzy or faint often.
• Unable to get out of a chair without using arms.
• Difficulty seeing or hearing.
• Problems thinking clearly or understanding.
• Taking medicines that make you sleepy or dizzy.
• Needing to rush to the toilet.
• Fear of falling that limits your activity.

Checking for risks helps identify who needs more help.

Medical Reviews

For those at high risk of falling, NICE suggests:

• Checking all medicines to see if any make falls more likely. Lower doses if possible.
• Testing vision and hearing and referring for treatment if necessary. Poor vision or hearing can affect balance.
• Conducting a full medical review to assess issues like dizziness, foot pain, heart rate problems, and more that could affect falls.
• Discussing options like adjusting medicine doses or physical therapy to improve balance.
• Checking bone strength if there are risks like osteoporosis and starting preventive treatment if needed.
• Assessing feet and stumbling risks and providing inserts or footwear advice when necessary.

Thorough reviews identify health factors to address.

Exercise Programs

For older adults who have fallen or are unsteady, NICE strongly recommends exercise programs to increase strength, balance, and coordination. Recommended programs include:

• Muscle strengthening exercises using weight machines, resistance bands, or body weight.
• Balance training through activities like backward walking, heel-to-toe steps, and Pilates.
• Tai Chi classes tailored to older users.
• Individual or group sessions with trained fitness instructors.
• Consistent exercise 2-3 times per week for at least 6 months.
• Referring for a physical therapy assessment if needed.

Staying active provides greater stability and confidence.

Home Safety Checks

NICE states that trained healthcare workers should make home visits after falls to suggest changes. They recommend:

• Improving lighting indoors and outside entrances, and adding nightlights.
• Adding grab rails in bathrooms and using bath seats.
• Removing tripping risks like rugs, clutter, and cables.
• Providing stable chairs and adjusting chair and bed heights.
• Installing ramps if needed and fixing outdoor walkways.
• Using slip-resistant mats and shower grips.
• Having emergency alarms or call buttons.
• Adjusting storage so things are within easy reach.

Removing hazards provides a safer environment.

Practical Support

For daily functioning, NICE guidelines suggest:

• Reviewing all aids like canes, walkers, and braces to ensure a suitable fit and proper training, and replacing worn grip handles.
• Providing mobility aids early rather than waiting until it’s very limited.
• Putting care plans in place for high-risk times like during illnesses.
• Having regular eye checks and providing new eyeglasses promptly when needed.
• Suggesting protective hip guards and helmets for those prone to falling.
• Ensuring adequate pain relief when needed.

Practical support aids independence and activity.

Information for Older Adults

NICE advocates giving older people tips on:

• How to correctly use walking aids and how to get up safely after a fall.
• Doing exercises to improve strength and balance and offering group classes.
• Having regular eye tests and getting new glasses on time.
• Watching out for trip hazards at home like rugs, pets, and clutter.
• Wearing shoes that provide good support and grip and avoiding slippery soles.
• Being cautious when walking in winter weather.
• Reporting any concerns about dizziness or unsteadiness early.

Informed people can better protect themselves.

Ongoing Risk Monitoring

For those at an elevated risk of falling, NICE recommends:

• Conducting frequent reviews to check current risk status and needs and updating plans.
• Referring back to the medical team promptly if new problems arise.
• Providing refreshers on home modifications, exercise routines, and aids.
• Reassessing medicines regularly for effects like drowsiness.
• Following up after any falls to understand why they occurred and updating interventions based on insights.
• Offering emotional support alongside practical assistance.

Regular checks sustain helpful actions over time.

it’s really important to be watchful and take action to stop slips, trips, and falls. This is a big deal for the safety and happiness of older people.

Falls prevention in care settings takes dedication, but it is highly beneficial for helping older people remain active and independent.

Following NICE guidelines on checks, health reviews, home changes, exercise programs, and practical support offers a proven plan. Staying alert to emerging needs is also crucial.

With the right preparation, people can stay comfortably mobile even as risks increase with age.

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• Macular degeneration is an eye condition that causes damage to the macula, which is the central part of the retina. ↩︎
• Glaucoma is an eye condition characterised by increased pressure within the eye, which can damage the optic nerve. Glaucoma is a leading cause of blindness worldwide. ↩︎
• Cataracts are like a cloudy cover over the eye’s lens, making the vision blurry and less clear. It’s common as people get older and can be fixed with surgery. ↩︎
• Parkinson’s disease is a medical condition (neurological disorder) that affects movement. It can cause symptoms like tremors, stiffness, and difficulty with balance and coordination. ↩︎
• Osteoporosis is a condition where the bones become weak and brittle, making them more likely to fracture or break. It is often referred to as “brittle bone disease.” Osteoporosis is common in older adults and can lead to fractures, especially in the hip, spine, and wrist. ↩︎
• Gait refers to the way a person walks or moves their legs when they walk. It involves the pattern and rhythm of steps while walking. ↩︎

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Slips, Trips, and Falls: Understanding, Preventing, and Mitigating Risks

By Gian Joseph, Safety Advisor

As we enter the rainy and cold season, we face several risks , which include slips , trips, and fall s in our day-to-day activities. It is important t o be aware of hazards around us and learn how to properly identify and assess any risks with each step.  

Slips, trips, and falls (STFs) are common accidents that can lead to severe injuries. These incidents occur in various settings, from homes and workplaces to public spaces , and i t is essential to understand the causes, consequences, and , most importantly, strategies for prevention and mitigation.   

1. Understanding the Dynamics of STFs. STFs are caused by the following .  

Insu fficient friction between the shoe and the walking surface. Common causes include wet or greasy floors, spills, and loose debris (Slip and Fall Accidents, 2021).  

When a person's foot collides with an object or an uneven surface, it caus es them to lose balance. Typical trip hazards include cluttered walkways, electrical cords, uneven flooring, and damaged or upturned mats (Slip and Fall Accidents, 2021).  

2. The Impact of STFs  

Slips, trips, and falls have far-reaching effects, affecting individuals and society . Personal i njuries range from minor cuts , bruises, sprains , and abrasions to fractures, dislocations, and head injuries (National Safety Council, 2021). The medical expenses associated with treating STF-related injuries can be substantial , including hospital stays, surgeries, rehabilitation, and ongoing care (National Safety Council, 2021). STFs can result in missed workdays and reduced productivity for both individuals and employers. Workers' compensation claims and absenteeism contribute to economic costs (National Safety Council, 2021). Lastly, t he physical and psychological consequences of STFs can limit mobility, independence, and overall quality of life, especially among older adults ( Sahyoun et al., 2020).  

3. Prevention and Mitigation Strategies  

Preventing and mitigating STFs involves a combination of awareness, environmental modifications, and education . H ere are some ways you can take precaution s against STFs in your daily activities;  

Clear Pathways: Maintain clear, unobstructed walkways by removing clutter and tripping hazards such as cords, toys, and loose rugs (Occupational Safety and Health Administration [OSHA], 2002).  

Adequate Lighting: Ensure proper lighting in all areas, both indoors and outdoors, to improve visibility and reduce the risk of tripping over obstacles (OSHA, 2002).  

Slip-Resistant Flooring: Install slip-resistant flooring materials, especially in areas prone to moisture, like bathrooms and kitchens (OSHA, 2002).  

Footwear: Encourage the use of proper footwear with good traction, especially in environments where slip hazards are prevalent ( Sahyoun et al., 2020).  

Handrails and Guardrails: Install and maintain handrails and guardrails on stairs, ramps, and elevated platforms to provide support and prevent falls (OSHA, 2002).  

Warning Signs: Use signage to alert individuals to potential hazards, such as wet floors or uneven surfaces (OSHA, 2002).  

Education and Training: Promote awareness and provide training to individuals on recognizing and avoiding STF hazards (National Institute for Occupational Safety and Health [NIOSH], 2015).  

Workplace Safety: Employers should implement safety protocols and conduct risk assessments in the workplace, addressing potential STF risks (NIOSH, 2015).  

Regular Maintenance: Routinely inspect and maintain buildings, walkways, and outdoor areas to identify and address potential hazards promptly (NIOSH, 2015).  

4. A Holistic Approach to STF Prevention  

Preventing and mitigating STFs require a collaborative approach involving individuals, organizations, and communities:  

Individuals : Exercise caution when walking, especially in unfamiliar or potentially hazardous environments. Wear appropriate footwear and take your time, especially in wet or slippery conditions ( Sahyoun et al., 2020).  

Employers: Create a safe work environment by identifying and mitigating STF risks. Provide training to employees on safety protocols and the proper use of equipment (OSHA, 2002).  

Property Owners and Managers: Ensure properties are well-maintained and free from hazards. Regularly inspect and address issues promptly (NIOSH, 2015).  

Government and Local Authorities: Enforce building codes and regulations that promote safety, especially in public spaces and commercial buildings (OSHA, 2002).  

Conclusion  

Slips, trips, and falls are preventable accidents that carry substantial personal, economic, and societal costs. By comprehending the causes, consequences, and prevention strategies, we can significantly reduce the incidence of STFs and mitigate their impact. Whether at home, at work, or in public spaces, prioritizing safety and fostering awareness about STFs is crucial for the well-being of individuals and communities. Let us strive collectively to create environments where everyone can move safely and confidently, free from the fear of falling.  

References:  

National Institute for Occupational Safety and Health (NIOSH). (2015). Preventing Slips, Trips, and Falls in Wholesale and Retail Trade Establishments. https://www.cdc.gov/niosh/docs/2015-100/pdfs/2015-100.pdf  

National Safety Council. (2021). Injury Facts. https://injuryfacts.nsc.org/work/overview/work-safety-introduction/work-...  

Occupational Safety and Health Administration (OSHA). (2002). OSHA Publication 3151-12R. Preventing Slips, Trips, and Falls in Wholesale and Retail Trade Establishments. https://www.osha.gov/Publications/osha3151.pdf  

Sahyoun , N. R., Pratt, L. A., & Lentzner , H. (2020). The Changing Profile of Nursing Home Residents: 1985-1997. Journal of Aging and Health, 12(3), 336-363.  

Slip and Fall Accidents. (2021). InjuryClaimCoach.com. https://www.injuryclaimcoach.com/slip-and-fall-accidents.html  

Please note that the sources cited are accurate as of the time of writing this article. For the most current information, consult authoritative sources and local health authorities.  

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• Pediatr Qual Saf
• v.7(2); Mar-Apr 2022

Slips, Trips, and Falls: A Quality Improvement Initiative

Gene h. peir.

From the 1 Children’s National Hospital, Washington, D.C.

2 George Washington University School of Medicine and Health Sciences, Washington, DC.

Nick Mantasas

Jenhao j. cheng, katherine worten, rahul k. shah, associated data, introduction:.

Employee safety and the reduction of Days Away, Restricted, or Transferred are a focus of the Solutions for Patient Safety Network. One significant contributor to the Days Away, Restricted, or Transferred rate at Children’s National Hospital is employee slips, trips, or falls.

Children’s National Hospital implemented a multidisciplinary quality improvement with executive leadership vision and support. We implemented quality techniques (including Key Driver Diagrams, Pareto Charts, and continuous Plan-Do-Study-Act) and designed novel Environmental Services interventions.

Children’s National Hospital achieved a 44.3% reduction in monthly average reported slips, trips, or fall events from baseline and sustained over a 2-year study period.

Conclusion:

A leadership-driven multidisciplinary approach to quality initiatives with team leaders capable of making and enacting real-time policy changes led to novel interventions and a successful reduction of employee slips, trips, and falls events over time, which are broadly generalizable.

INTRODUCTION

Employee safety has trailed advances in patient safety. In the late 1980s, Paul O’Neill revolutionized employee safety by creating a system for reporting accidents and injuries and analyzing root causes to identify deficiencies. He believed and ultimately proved that a focus on employee safety would increase overall productivity and profitability. 1 , 2 In healthcare, serious, nonfatal workplace injuries total 2 billion dollars nationwide in workers’ compensation, with 6.8 work-related injuries and illnesses for every 100 full-time employees in 2011. 3 Groups such as the Institute for Healthcare Improvement have credited Mr. O’Neill for establishing the basic tenants of employee safety that continue to guide their philosophy today. 4 The Children’s Hospital’s Solutions for Patient Safety (SPS) Network includes 145+ member hospitals working together to eliminate serious harm across all children’s hospitals. 5 Excitingly, SPS partnered with and consulted with Mr. O’Neill to draw employee and staff safety in hospitals to the forefront of their work. As a result, SPS formally launched the work on employee and staff safety in 2016, where quality and safety leaders came together to accomplish several objectives, which included: creating awareness of the scientific evidence linking employee/staff safety to patient safety, reviewing best practices from other industries related to employee/staff safety work, and presenting and recommending SPS Network-wide goals. 6 One of the stated goals of the SPS collaborative is to achieve a 25% reduction in network Employee/Staff Days Away, Restricted, or Transferred rate, 6 a safety metric tracked by the Occupational Safety and Health Administration. 3 SPS recognizes Slips, Trips, and Falls as a focus area contributing to the overall Days Away, Restricted, or Transferred rate. 6

Previously published works have demonstrated the success of leadership-driven programs to improve patient safety and eliminate preventable harm. For example, Nationwide Children’s in 2008 developed the “Zero Hero” program to provide a face to their message of improving patient safety. 7 In 2017, following the footprint established by other institutions, Children’s National Hospital’s President and Chief Executive Officer, along with the Board of Directors and Executive Leadership encouraged and supported management to launch a centralized, hospital-wide Employee and Staff Safety (ESS) Program 8 to create a safer work environment for employees and decrease the institutional Days Away, Restricted, or Transferred rate, which at 1.48 8 was above the national benchmark of 1.15. 9 The group reviewed baseline data and identified five employee injury focus areas based on the frequency of events and staff most vulnerable to harm. The focus areas included sharps injuries, blood and body fluid exposure, workplace violence, slips, trips, falls, and overexertion injuries. 8 We have previously reported on the success of our broad employee staff safety work to create a safer work environment. 7

The prior article was overarching; it demonstrated the role of a system-wide programmatic effort to tackle the problem of employee staff safety and addressed sharps injuries, blood and body fluid exposures, workplace violence, overexertion, and slips, trips, and falls from a macro perspective. 8 The current report details the specific quality improvement initiative aimed to decrease the number of slips/trips/falls by 20% initially in the first 6 months of FY 18 and sustain for 1 year within Children’s National Hospital owned and operated facilities. The group chose a target of 20% as an attainable goal to target in the first 6 months. Anecdotally, it has become apparent that hospitals struggle in specific focus areas under the employee staff-safety work. Therefore, it is imperative to present shared learnings in this area of the employee staff-safety work. The results demonstrate the institutional leadership and multidisciplinary approach required to make significant improvements to employee safety, acknowledging that this work is generalizable within an organization’s employee safety operations other organizations.

This project was deemed exempt from Institutional Review Board approval as a quality improvement project. Children’s National Hospital, located in Washington, DC, is an urban, tertiary-care, 323-bed free-standing academic children’s hospital, with approximately 8000 employees.

The quality and safety initiatives at Children’s National Hospital have undergone many iterations, starting in 2006 and again embarking on the second iteration in 2012. 10 The framework in 2014 for patient safety led to significant organizational improvements in patient safety and quality. As a result, executive leadership challenged the organization to create similar employee and staff safety processes. Initially, the Employee and Staff Safety Steering (ESS) Committee 8 was created, tasked with advancing the safety culture at Children’s National Hospital, and reducing harm to employees. The multidisciplinary committee, chaired by the Vice President, Chief Quality and Safety Officer, and the Vice President, Chief Risk Officer, included representatives from Risk Management, Patient Safety, Workers’ Compensation, Nursing, Security, Environmental Services (EVS), Occupational Health, Human Resources, and Performance Improvement. As described previously, 8 the group highlighted five employee injury focus areas based on the frequency of events and staff most vulnerable to harm: sharps injury, blood, and body fluid exposure, workplace violence, slips/trips/falls, and overexertion. In addition, the committee chose team leads based on expertise and appropriate oversight for instituting change in real-time to address each area.

The ESS Committee named the Environmental Services (EVS) Director team lead of the slips/trips/falls focus area; team members included EVS managers and supervisor. The safety and quality team provided support, guidance, and insight. The team followed OHSA definitions: slip is the lack of traction between footwear and walking surface; a trip impedes lower extremity movement. A fall is a total loss of balance from the same or lower level. 3 Before inclusion in the data, the team leader carefully reviewed and evaluated the events. Ongoing injury data came from safety event reports, Occupational Health records, and Worker’s Compensation events.

At Children’s National Hospital, the ESS slips/trips/falls subgroup performed baseline analysis and identified 91 injury incidents in FY 2017. The team created a Pareto chart (Fig. ​ (Fig.1) 1 ) to categorize the areas of injury for intervention. In addition, they created key driver diagrams ( see figure 1, Supplemental Digital Content 1, http://links.lww.com/PQ9/A369 ) through data analysis, review of best practices, and staff feedback. The group met quarterly to assess intervention success; the team analyzed Pareto charts and developed subsequent Plan-Do-Study-Act cycles based on data gathered for the previous quarter. In addition, the EVS team met weekly to provide immediate feedback to the group leader.

Pareto chart FY 2017, slips/trips/falls

Based on initial data, wet floors caused 41% of slips, trips, and falls. Next, the team investigated individual cases and identified several areas for improvement and intervention (Table ​ (Table1). 1 ). First, the team installed large moisture mats at all transition points and extended outward and inward following PDSA re-evaluation to address entrances. Second, EVS placed stands with plastic bags strategically at main entrances; security officers instructed visitors to use those bags on PDSA re-evaluation. Third, we aggressively placed wet floor signage surrounding select high-traffic restroom areas. Additionally, we installed push button alert technology to report unsafe conditions in these areas. When pressed by the user, the button alerts the EVS staff to an area requiring attention, allowing faster response time. Finally, elevator areas utilized more mats and signage for transition points.

Wet Floor Injury Areas of Focus

In areas of active EVS cleaning, we implemented multiple interventions over several PDSA cycles. Initially, EVS workers placed wet floor signage at either end of the work area. Despite the signage, staff continued to enter work areas unintentionally through the alternative entrance and exit points within the work. EVS subsequently proceeded to rope off the entire work area, preventing this phenomenon. In addition, EVS informed the charge nurses of pending work to alert bedside staff in clinical areas. Finally, in addressing elevators, the EVS staff partnered with the security department to stop and rope off active areas until floors were dry to minimize the chances of injury.

The team launched the “Lid On” campaign to promote using lids on drink containers and saran wrap to cover all food and drink products, leaving the cafeteria area to address cafeteria slips. In addition, Saran wrap stations were increased and made more visible, and wet floor signs were proactively placed around the cafeteria to bring attention to the high-risk areas.

Other Areas

Obstacles causing injury were primarily parking garage speed bumps and uneven ground trips. We addressed these obstacles by painting the speed bumps bright yellow to make them more noticeable addressed old areas of uneven pavement. During the winter months, outdoor weather conditions related to icy conditions were especially prevalent at various outpatient outreach centers. These centers mainly were properties that the organization did not own; instead, they were leased. To address this, the group proactively reached out to landlords to request the salting of sidewalks before the known risk of snow and ice buildup. On the institutional campus, EVS proactively salted outdoor areas before the risk of snow and ice. The balance category included instances of injury where a review identified no modifiable cause, and the reason for the slip was human error.

Injury Prevention Kits

To augment the specific interventions, the EVS installed multiple “kits” to assist staff in high-risk areas to minimize the possibility of injury. The first was a “Spill Kit.” This kit consisted of rapidly deployable wet floor signs and absorbent pads to soak up wet areas until EVS staff arrived at the scene. In addition, the welcome desk staff deployed this kit at major entrances when necessary.

To address injury within the EVS staff during cleaning, we created a “Floor Care Kit.” When deployed to an area of interest, it included a checklist of items: nonslip shoe covers, wet floor signs, absorbent pads, caution tape, gloves, painter’s tape, and a mop head.

Organizational Awareness

In 2018, Children’s National Hospital launched a “Your Safety Matters Too” campaign to raise awareness of organizational commitment to reducing employee harm, similar to the concept established by the “Zero Harm” campaign. 7 Team leads and the ESS Steering Committee regularly rounded with staff to raise awareness. The Daily Check-In safety briefing incorporated reports on injury or safety events to increase awareness and escalate concerns. In addition, we integrated ESS content into new hire training, which ensured that all new staff, including select vendors, coming into the organization understood the importance of employee safety and the processes in place to minimize injury.

Statistical Analysis

A statistical process control c-chart tracked the monthly number of safety events and informed the progress. We started the process improvement in June 2018 using Nelson’s Shift Rule. 11 We use data points following the new process implementation to calculate a new centerline. We apply the Pareto Chart, an intuitive quality tool based on ordered frequencies and accumulation, to each fiscal year to identify the top reasons that caused the injuries. Finally, we used statistical tests based on Poisson distribution to compare the total number of events in a fiscal year to the total number in an earlier year to check if the difference (reduction or improvement) is statistically significant or not.

Outcome Measures

Children’s National Hospital had a 44.3% reduction in the average monthly count for the slips/trips/falls events after the baseline period of FY17 according to the centerline shift as noted on the c-Chart (Fig. ​ (Fig.2), 2 ), from 7.348 to 4.091 with a statistically significant difference of -3.257 (95% CI: −4.887, −1.627; P < 0.001). Of note, January and February 2019 saw a significant jump in falls in parking lots due to icy conditions caused by successive snowstorms. However, these incidents did not occur within the scope of a Children’s National Hospital-owned and managed facility and are excluded from the analysis.

Slips, trips, and falls c-chart

Process improvement was also compared with the overall count of slips, trips, and falls for different fiscal years, as shown in Table ​ Table2. 2 . The annual total count decreased from 91 in FY17 to 83 in FY18 by 8.8% and from 83 in FY18 to 61 in FY19 by 26.5% in stepwise increments with an insignificant difference of -8 (95% CI: −33.9, 17.9; P = 0.545) and marginal difference of −22 (95% CI: −45.5, 1.5; P = 0.067), respectively. The decrease from 91 in FY17 to 61 in FY19 by 33% is a statistically significant difference of −30 (95% CI: −54.2, −5.8; P = 0.015). We base the significance on Poisson distribution because the data are the counts of rarely occurring safety events.

Year to Year Comparison of Overall Slips/Trips/Falls

The makeup of injury events evolved over the 2-year study period as well. Compared with baseline data from FY17, as seen in Figure ​ Figure1, 1 , the Pareto charts for FY 18 (Fig. ​ (Fig.3) 3 ) and FY 19 (Fig. ​ (Fig.4) 4 ) detail the composition of the reason for falling. For example, initial data from FY 2017 showed that the highest percentage (50%) of injuries were attributable to wet floors; by FY2019, wet floors no longer caused the largest percentage of injury, accounting for only 16% of cases.

Pareto chart FY 2018, slips/trips/falls

Pareto chart FY 2019, slips/trips/falls

This report details a single free-standing Children’s Hospital experience improving organizational slips, trips, and falls. We accomplish this within a comprehensive Employee Staff Safety program driven by hospital leadership previously described. 8

Mitchell et al’s October 2012 commentary from the Institute of Medicine’s Best Practices Innovation collaborative highlighted the importance of high-functioning teams in health care. 12 They establish that shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes are the fundamental principles of team-based health care. 12 The importance of a multidisciplinary team structure cannot be overstated; it requires content expertise with authority to carry out real-time changes and quality experts providing guidance.

This concept is seen in Fred Lunenberg’s description of power and leadership. 13 He lays out the five sources of power in two categories: organizational power and personal power. 13 Organizational power contains three subtypes: legitimate power that comes from the position an individual holds within an institution and their authority over other members of the institution; reward power is a person’s influence over others’ behavior by providing them with things they want; coercive power is a person’s ability to influence others’ behavior by punishing them or by creating a perceived threat to do so. Personal power has two subtypes: expert power is a person’s ability to influence others’ behavior because of recognized knowledge, skills, or abilities; referent power is a person’s ability to influence others’ behavior because they like, admire, and respect the individual.

It is important to have a leader and members who possess various power forms to ensure the group is productive and successful in a multidisciplinary team structure. In this experience for slips/trips/falls, the Director of EVS oversaw the workgroup. His expertise in the area gave him expert power to make well-informed decisions. His direct supervision of managers and legitimate power that provided direct communication with EVS employees allowed for a real-time change in practice and feedback. This model can be applied to building a team to address any focus area within employee safety or, more broadly, across quality improvement initiatives hospital-wide, where an inefficient team can impede progress.

The EVS partnership with other disciplines, including nursing, security, and food services representatives, facilitated a unified and consistent message and a plan for slips/trips/falls prevention in high traffic areas of the hospital. The quality experts regularly reconvene the workgroup to review progress and update key driver diagrams in real-time to adjust the strategies effectively. In addition, due to this collaboration, the group was able to create “kits” to tackle areas of high injury rate, including the “Spill Kit” and “Floor Care Kit.”

As the work progressed over time, the impact was reflected in the total number of overall Slip/Trip/Fall injuries and the etiologies of those injuries. There was a natural evolution in the area’s initial focus, vis-a-vis the area with the highest percentage of injury, wet floor transitions. As such, it became clear the importance of continued analysis using Pareto charts to allow a more broad and real-time understanding of where the injuries continued to occur with the highest frequency. Key Driver Diagrams are modified to address these updated identified areas of interest. Overall, the process identified several critical areas tackled in a sequence of highest priority based on frequency as identified by Pareto chart analysis. It is crucial to constantly evolve the Key Driver Diagram to ensure it remains relevant and actionable.

Importantly, we believe this work is novel in its approach to addressing Slips/Trips/Falls; it is also generalizable to two broad areas: continued ESS work within the institution in other areas of employee injury outside of Slips/Trips/Falls and other institutions looking for a process map for making improvements to benefit employee safety. For example, at Children’s National Hospital, similar processes are taken to address sharps injuries, overexertion injuries, fluid exposures, and verbal and physical violence.

The limitations of this study include the inability of the group to control all aspects of the causes of injury, most notably injury attributed to an accident on the fault of the employee that was unrelated to the environment, as well as injury at locations where Children’s National Hospital was not the landlord and therefore had no direct ability to modify the environment. However, with an appropriate selection of group leaders able to directly intervene in the areas of interest and the support of a multidisciplinary group and quality improvement experts, change can be implemented to improve one domain affecting employee safety and sustained over a multiyear period.

ACNOWLEDGMENTS

There are no others who assisted with this study. There was no financial support or sponsorship of this study. The authors have no conflicts of interest to disclose. These data have not previously been presented.

The authors have no financial interest to declare in relation to the content of this article.

Supplementary Material

Published online March 30, 2022

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

To cite: Peir GH; Fink A; Mantasas N; Cheng JJ; Worten K; Shah RK. Slips, Trips, and Falls: A Quality Improvement Initiative. Pediatr Qual Saf 2022;7:e550.