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J Nurs Care Qual
Vol. 33, No. 1, pp.

–28
Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

Multilevel Factors Associated
With Injurious Falls in Acute
Care Hospitals

Yunchuan (Lucy) Zhao, PhD, MPAff, RN;
Marjorie Bott, PhD, RN; Jianghua He, PhD;
Heejung Kim, PhD, RN; Shin Hye Park, PhD, RN;
Nancy Dunton, PhD, RN

Using National Database of Nursing Quality Indicators data from July 2013 to June 2014, this cor-
relational study examined the associations of injurious falls among all patient falls with multilevel
factors in hospitals. The sample included all falls recorded in adult medical, surgical, combined
medical-surgical, and step-down units (N = 2299) in participating hospitals (N = 488). Hierar-
chical negative binominal regression analyses were performed. Results revealed hospital and unit
organizational factors associated with inpatient injurious falls. Key words: fall risk assessment,
falls, hospitals, injurious falls, nurse staffing, organizational structure

INPATIENT FALLS and injurious falls inacute care settings are prevalent and a se-
rious concern for patient care. In the United
States, the overall prevalence of falls range
from 3 to 5 falls per 1000 patient-days,
with about 1 million inpatient falls annually.1

Among inpatient falls, the incidence rates for
fall-related injuries range from 6.8% to 72.1%,
with 0.7% to 30% for severe injuries such as
fractures, cranial trauma, or death.2 Injurious

Author Affiliations: Boise State University School of
Nursing, Boise, Idaho (Dr Zhao); University of
Kansas School of Nursing (Drs Bott, Park, and
Dunton) and Department of Biostatistics, University
of Kansas School of Medicine (Dr He), Kansas City;
and College of Nursing, Yonsei University, Seoul,
South Korea (Dr Kim).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article
on the journal’s Web site (www.jncqjournal.com).

Correspondence: Yunchuan (Lucy) Zhao, PhD, MPAff,
RN, Boise State University School of Nursing, 1910
University Dr, Mail Stop 1840, Boise, ID 83725
(lucyzhao@boisestate.edu).

Accepted for publication: January 15, 2017

Published ahead of print: March 20, 2017

DOI: 10.1097/NCQ.0000000000000253

falls have a negative impact on patients, fami-
lies, and the health care system. With injurious
falls, patients may suffer from loss of indepen-
dence, depression, and decreased quality of
life.1 Injurious falls can result in a prolonged
length of stay (LOS) that further leads to in-
creased direct patient care costs and health
care resource use.1 When comparing patients
with severe injurious falls with patients with-
out falls, the LOS increases, on average, by 6 to
12 days, with an additional cost of $13 316 for
the patient.3 In addition, indirect costs asso-
ciated with injurious falls may include loss of
income, placement in a skilled nursing facility
or nursing home, and litigation expenses.1,3

In the last few decades, interventions aimed
at fall prevention have been developed and
implemented in hospitals.4 Several national
initiatives also have underscored the impor-
tance of preventing falls and their associated
adverse consequences. Prevention of falls and
fall-related serious injuries and death is one
major goal in the Healthy People 2020.5 Be-
ginning in October 2008, the Centers for
Medicare & Medicaid Services no longer reim-
burses hospitals for treatment of preventable
injuries, including fall-related injuries.6 De-
spite the national efforts and initiatives on

http://www.jncqjournal.com

mailto:lucyzhao@boisestate.edu

Injurious Falls in Acute Care Hospitals 21

fall prevention, inpatients falls and fall-related
injuries still are prevalent in hospitals. The
results of a recent study show a total of
315 817 falls (3.56 falls per 1000 patient-days),
with 26.1% (82,332) of the falls having re-
lated injuries (0.93 injurious falls per 1000
patient-days) in less than a 2-year period in
US hospitals.7

Inpatient falls are a complicated phe-
nomenon that involves multilevel factors,
including patient-specific factors, envi-
ronmental factors, organizational factors,
and patient-staff interaction factors in the
hospital.1 Research shows that patients
identified at risk for falls are more likely to
experience injurious falls.8 Evidence of the
associations between gender and injurious
falls is controversial.8-11 Hospital character-
istics such as hospital size and Magnet or
teaching status are associated with injurious
falls. Small hospitals (<300 beds) tend to have more injurious falls,11,12 whereas Magnet and teaching hospitals have fewer inpatient falls and injurious falls, respectively.11,13

Unit factors (eg, unit types and nurse
staffing) also are found to be associated with
injurious falls. Among medical, surgical, and
medical-surgical units, medical units have
the highest prevalence of falls and injurious
falls.7,9,11 Based on a systematic review and a
meta-analysis, the evidence on the association
between inpatient falls and nurse staffing is
inconclusive,14,15although some studies sug-
gest that lower inpatient fall rates are associ-
ated with higher nursing hours, higher regis-
tered nurse (RN) hours, and a higher propor-
tion of RN hours.13

Nursing care process factors also contribute
to inpatient falls and associated injuries. Stud-
ies show that fall risk assessment and fall
protocol implementation help prevent or re-
duce injurious falls.8,11 Falls without em-
ployee assistance are more likely to result
in injuries8,10,11 However, the use of phys-
ical restraints is positively associated with
an increased risk for falls, injuries, and even
death.16,17

Given the controversial evidence on factors
associated with injurious falls in the literature
and the complicated nature of inpatient

falls and associated injuries, further study
integrating multilevel factors contributing to
injurious falls is required. Using a modified
Donabedian’s Structure-Process-Outcome
(SPO) model18,19 that included patient
characteristics in the SPO model, this study
examined multilevel factors associated with
injurious falls in acute care hospitals (see
Supplemental Digital Content, Figure 1, avail-
able at: http://links.lww.com/JNCQ/A323).
To date, this study is the first attempt at
investigating the complex phenomenon of
injurious falls at multiple levels. The research
question was “What organizational structure,
unit structure, nursing care process, and
patient factors are associated with injurious
falls in acute care hospitals?”

METHODS

Design and data source

The study is a cross-sectional, correlational
design, using the National Database of Nursing
Quality Indicators (NDNQI) data collected be-
tween July 2013 and June 2014. The nursing
quality indicators such as falls and injurious
falls in NDNQI are National Quality Forum–
endorsed measures that have demonstrated
strong reliability and validity.20,21

Only adult (≥18 years) patients who had
any fall event on medical, surgical, medical-
surgical, and step-down units in acute care
hospitals during the study period were se-
lected for this study; patient-level fall data
then were aggregated to the unit level.
NDNQI monthly data were aggregated into
annual data at the unit level or hospital level.
The final sample included 2229 units (medi-
cal = 587; surgical = 412; medical-surgical =
795; and step-down = 435) in 488 hospi-
tals. This study was determined to be nonhu-
man subject research by the Human Subjects
Committee at a Midwestern academic medical
center.

Measures

Injurious falls

The annual total number of injurious falls
among all inpatient falls at the unit level was

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22 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2018

the outcome variable. NDNQI defines a fall as
“sudden, unintentional descent, with or with-
out injury to the patient, that results in the pa-
tient coming to rest on the floor, on or against
some other surface (eg, a counter), on another
person, or on an object (eg, a trash can).”22(p2)

Injurious falls are falls with any injuries from
minor to death.22

Structure, process, and patient factor

Independent variables included structure,
process, and patient factors. Structure fac-
tors had 2 levels: hospital and unit. Hospi-
tal characteristics were categorized into hos-
pital bed size (small: <100; medium: ≥100 to <300; and large: ≥300), teaching status (teaching and nonteaching), and Magnet sta- tus (Magnet and non-Magnet). Unit structure factors included unit types (ie, medical, sur- gical, medical-surgical, and step-down) and nurse staffing factors. Nurse staffing on the unit consisted of 5 continuous variables: to- tal nursing hours per patient-day (TNHPPD), RN hours per patient-day (RNHPPD), non- RNHPPD (calculated by subtracting RNHPPD from TNHPPD), RN skill mix, and RN turnover rate.

The following process and patient factors
reported by NDNQI for each inpatient fall
were first coded into dichotomous variables
from monthly data files and then aggregated
and summed across months into annual data
at the unit level that represent the propor-
tions of certain characteristics among patients
who fell in the units. Fall risk assessment was
measured by whether a fall risk assessment
was performed on the patient prior to the
fall. Implementing fall prevention protocol
was measured by whether a documented fall
prevention protocol had been implemented
prior to the fall. Falls with employee assis-
tance were defined as falls in which the pa-
tient was assisted by a staff member, and the
patient’s descent was slowed by the staff in
an effort to minimize the fall impact.22 Phys-
ical restraint(s) use was measured with any
physical restraints that were in use at the
time of patient fall.22 Patient gender was re-
ported as either male or female. Patient fall

risk status was determined on the basis of the
most recent risk assessment. The estimated
coefficient is related to the change of every
10 percentage points at the unit level.

Data analyses

All statistical analyses were conducted with
STATA 14 (StataCorp LP, College Station,
Texas). Both descriptive and regression anal-
yses were performed. Prior to the regres-
sion analyses, correlation and interaction tests
were carried out to examine the correlations
and interactions among independent vari-
ables. Because of strong correlations between
RNHPPD and TNHPPD (r = 0.81), RNHPPD
and RN skill mix (r = 0.53), only RNHPPD,
non-RNHPPD, and turnover rate among nurse
staffing factors were included in the models
for analyses. A quadratic term of RNHPPD also
was included in the models to test the poten-
tial nonlinear relationship between injurious
fall rates and RNHPPD.

The hierarchical negative binominal regres-
sion model was used to account for the
complex sample with multiple units within
hospitals.23 In the regression model, the an-
nual count of total injurious falls at the unit
level was the outcome measure, with the an-
nual count of total falls at the unit level as the
exposure variable. Falls with missing data on 1
or more variables were excluded. In addition
to the fixed effects of independent variables, a
random hospital intercept was included in the
model to control for the correlation among
units within a hospital. The STATA procedure
menbreg for multilevel data was used for mod-
eling, with the significance level set at .05. The
incidence rate ratios (IRRs) were estimated
to show the associations of independent vari-
ables with the injurious fall rate.

For model selection, a teardown method
was used. The initial model included all 17
predictor variables. Variables within a group
(ie, structure, process, nurse staffing, and
unit type) with large P values were removed
(P > .05) and the resulting reduced model
was tested and compared with the previous
model. Using the Akaike information criterion
(AIC) value as a criterion, multiple models

Injurious Falls in Acute Care Hospitals 23

were tested and the final model included 6
significant predictor variables with the small-
est AIC value.

RESULTS

Descriptive analysis

The frequencies and descriptive statistics
are shown in Supplemental Digital Content,
Table (available at: http://links.lww.com/
JNCQ/A324). Hospitals with medium bed size
or teaching status accounted for about one-
half of the sample, whereas Magnet hospi-
tals were about 20% of the sample. Medical-
surgical units (35.7%) accounted for the most
units included in the sample of 2229 units.
There were on average 78.9 reported falls
(range, 1-864) and 5.2 injurious falls (range,
1-31) annually across the units during the
study period. The average patient-days were
17.11, ranging from 0.36 to 110.24 (unit: 1000
patient-days). RNHPPD on average was 6.28,
with a range of 1.15 to 14.96.

Hierarchical regression analysis

Hierarchical regression modeling was used
to estimate the associations between predica-
tor variables and the injurious fall rate. The
Table lists IRR values, with 95% confidence
intervals and P values for different variables
included in the initial and final models.

Hospital characteristics

Among hospital structure characteristics,
teaching status was the only significant vari-
able. Compared with falls in nonteaching hos-
pitals, falls in teaching hospitals were 13% less
likely to be injurious falls (P = .001). There
was no significant difference between Mag-
net and non-Magnet hospitals and among hos-
pitals with different bed sizes.

Unit characteristics

Falls on surgical units were 8% more likely
to be injurious falls than those in other units
(P = .021). No significant differences were
found in non-RNHPPD and turnover rate on
injurious fall rates. RNHPPD was the only
significant variable among nurse staffing

factors that showed a significant nonlinear
relationship with injurious falls. On the basis
of the estimated coefficients of linear and
quadratic terms of RNHPPD, the injurious fall
risk was estimated to be lowest at 5.08 RNH-
PPD. With all the other independent variables
controlled, the injurious fall risk was ex-
pected to decrease with increasing RNHPPD
till RNHPPD reached 5.08. After RNHPPD
reached 5.08, the expected injurious fall risk
increased with increased RNHPPD. Supple-
mental Digital Content, Figure 2 (available
at: http://links.lww.com/JNCQ/A325), shows
the relationships between injurious fall risk
and RNHPPD based on models estimated
for the 4 different unit types separately.
This figure shows the consistent nonlinear
association across different unit types ex-
cept for medical units. The variable, 1000
patient-days (total annual patient-days on the
unit divided by 1000), also was identified to
be a significant factor: with every 1000-day
increase in patient-days, there was likely a 2%
decrease in injurious fall risks (P < .001).

Nursing process factors

Among nursing process factors, falls with-
out employee assistance was the only signifi-
cant factor. At the unit level, the risk of injuri-
ous falls was expected to increase by 4% when
the percentage of falls without employee as-
sistance increased by 10 percentage points
(P = .005). In addition, the risk of injuri-
ous falls was expected to decrease by 2.5%
when the percentage of patients at fall risk in-
creased by 10 percentage points on the units
(P = .009).

In addition to fixed effects, the random ef-
fect of the model was estimated for the hos-
pital level. The injurious fall rates for an indi-
vidual hospital might vary from 19% lower to
24% higher than the average injurious fall rate
of all hospitals, assuming all other variables
are fixed.

DISCUSSION

The major contribution of the study is
the examination of the associations between

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24 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2018

Table. Estimates of Associations Between the Injurious Fall Rate and Predicator Variables

Initial Model (AICa = 9368.685) Final Model (AIC = 9351.538)

Fixed Effects IRR (95% CI) P IRR (95% CI) P

Bed size (large vs)
Small 1.10 (0.95-1.26) .205 . . . . . .
Medium 1.04 (0.94-1.15) .412 . . . . . .

Teaching 0.88 (0.81-0.96) .004 0.87 (0.80-0.94) .001
Magnet 1.00 (0.91-1.11) .942 . . . . . .

Unit type (medical vs)
Surgical 1.07 (0.99-1.16) .066 1.08 (1.01-1.16)b .021
Medical-surgical 0.97 (0.91-1.04) .424 . . .
Step-down 0.98 (0.90-1.06) .576 . . . . . .

RNHPPD 0.86 (0.78-0.95) .002 0.86 (0.78-0.95) .002
RNHPPD2 1.01 (1.01-1.02) <.001 1.01 (1.01-1.02) <.001 Non-RNHPPD 1.00 (0.97-1.04) .788 . . . . . . Turnover 0.99 (0.99-1.00) .211 . . . . . . Annual patient-days

(1000 d)
0.98 (0.99-1.00) <.001 0.98 (0.98-0.982) <.001

Male genderc 1.00 (0.98-1.02) .905 . . . . . .
At fall riskc 0.978 (0.96-0.99) .033 0.975 (0.96-0.99) .009
No risk assessmentc 1.00 (0.95-1.06) .865 . . . . . .
No fall protocol

implementationc
1.01 (0.98-1.03) .561 . . . . . .

Restraint in usec 1.02 (0.96-1.07) .525 . . . . . .
Falls without employee

assistancec
1.04 (1.01-1.07) .005 1.04 (1.01-1.07) .005

95% Range of 95% Range of
Random Effects SD (95% CI) Variation SD (95% CI) Variation

Hospital level 0.11 (0.09-0.14) (0.81-1.24) 0.11 (0.09-0.14) (0.81-1.24)

Abbreviations: AIC, Akaike information criterion; CI, confidence interval; IRR, incidence rate ratio; RN, registered nurse;
RNHPPD, RN hours per patient-day; SD, standard deviation; 95% range of variation = [exp (−1.96 SD), exp (1.96 SD)];
TNHPPD, total nursing hours per patient-day.
aAIC is a model selection criterion, with a smaller value indicating a better model fit.
bSurgical units versus all other units.
cThis variable is a proportion. The IRR is estimated for every 10 percentage points increase in the variable for better
interpretation.

injurious falls and multilevel factors using the
most recently available NDNQI data (2013-
2014). The multilevel factors included in this
study were hospital and unit characteristics
as well as unit-level patient characteristics.
One unique aspect is that the study focused
on injurious fall rates only among adult in-
patients with falls, whereas previous studies
examined falls or injurious fall rates among

all inpatients. Given this unique aspect of this
study, the results may not be comparable with
findings from previous studies, although pre-
vious findings could provide some meaningful
background information.

In this study, falls in teaching hospitals
were 13% less likely to be injurious falls.
Although no previous studies have focused
on injurious falls among adult inpatient falls,

Injurious Falls in Acute Care Hospitals 25

the findings from a study examining injurious
falls among adult inpatients suggested that
patients tended to have fewer injurious falls in
teaching hospitals.11 Because organizational
culture emphasizes quality and safety in
teaching hospitals, quality of care and patient
safety often are institutional priorities.24

In addition, teaching hospitals often have
positive work environments compared with
nonteaching hospitals25; this also contributes
to better quality of patient care. Evidence
shows that hospitals with better work en-
vironments have better quality of care and
patient outcomes.26,27 This was validated in
this study, with the low occurrence of inju-
rious falls (IRR = 0.87; P = .001) in teaching
hospitals. This finding has important clinical
implication. To decrease injurious falls and
increase patient care quality, hospital and
nursing leadership can develop strategies
to emphasize quality and safety, promote
positive work environment, and increase
nurse job satisfaction.

Interestingly, Magnet status was not associ-
ated with injurious falls among inpatient falls
in this study. In the literature,7 Magnet hospi-
tals were found to have fewer injurious falls
among adult inpatients than among those in
non-Magnet hospitals, whereas findings of the
associations between falls and Magnet status
were inconclusive.13,28,29 Findings from pre-
vious studies reported a significant negative
relationship between hospital size and injuri-
ous fall rates among all adult inpatients.11,13

However, in this study, the association was
nonsignificant between hospital size and in-
jurious fall rates among inpatients with falls.
Because the results from this study are not
comparable with findings from other studies
on injurious falls due to different samples (ie,
all adult inpatients vs inpatients with falls)
and the inconclusive findings on the associa-
tions between hospital Magnet status and bed
size, more research is needed to explore the
associations.

Several significant unit factors including
unit type and unit staffing were associated
with injurious inpatient falls. The findings
from this study indicated that falls on surgi-

cal units were 8% more likely to be injurious
falls than those on medical units. Although no
similar findings could be identified in the lit-
erature, a longitudinal study reported that sur-
gical units had increased fall rates from 2004
to 2009.29 The increased fall and injurious fall
rates in surgical units might be associated with
the outcomes of the Enhanced Recovery Af-
ter Surgery (ERAS) programs implemented in
acute care hospitals. In the ERAS programs,
patients usually start early postoperative mo-
bilization and have a shorter LOS than those
in traditional operative programs.30,31 Early
postoperative mobilization can cause ortho-
static intolerance, which further can lead to
falls or fall-associated injuries.32 Our study
finding also suggested that the variable of
1000 patient-days was negatively associated
with injurious falls. Patient-days, particularly
1000 patient-days, have been used widely
in nursing research for nursing quality mea-
surement such as inpatient falls and pressure
ulcers.11,15 Given the fact that patients in the
ERAS programs tend to have shorter LOS, and
the negative association between injurious fall
risk and 1000 patient-days, further research
on injurious falls should be conducted on sur-
gical units through comparing injurious fall
rates in units implementing ERAS programs
with those without ERAS programs.

In our findings, unit RNHPPD was the only
significant predictor among nurse staffing
factors, although the association between
RNHPPD and injurious falls was nonlinear.
There were negative relationships between
injurious fall rates and RNHPPD for up to 5
RNHPPD; the relationships became positive
after RNHPPD reached 5. To date, this study
was the second study that examined the
association between injurious fall rates and
RNHPPD.13 Dunton and colleagues13 identi-
fied similar nonlinear associations between
injurious fall rates among inpatients and TNH-
PPD for medical units and RN skill mix for
step-down units, with a changing point at 9.

The different findings on the associations
between nurse staffing and injurious fall rates
and general fall rates might be due to the
differences in the outcome variables of the

26 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2018

studies. In this study, the primary outcome
was injurious fall rates from those patients
who had a general fall, whereas other studies
focused just on general falls. The nonlinear
relationship between injurious fall rates and
RNHPPD also may be related indirectly to pa-
tient acuity levels. In the last few decades,
many hospitals have implemented Acuity
Adaptable Model (AAM) in delivering patient
care.33-35 In AAM, postsurgical patients admit-
ted from the intensive care unit or a step-down
level of care through discharge and nurse
staffing levels are based on patient acuity lev-
els. In general, these patients are at higher
acuity level and require higher nurse staffing
levels.34 It is uncertain how many units in this
study have implemented the AAM. Thus, the
researchers cannot draw the conclusion that
the nonlinear association between injurious
fall rates and RNHPPD was due to different
patient acuity levels.

The nonlinear association between injuri-
ous falls and RNHPPD calls for appropriate
RN staffing in acute care settings. Nurse man-
agers need to ensure adequate RN staffing,
especially at the lower levels of RNHPPD (ie,
up to 5.08 hours), because RN understaffing
can place patients at high risk for injurious
falls. Nurse managers need to be cognizant
of patient acuity levels to ensure adequate
RN staffing. Further research is needed to in-
clude patient acuity levels in exploring the as-
sociation between RNHPPD and injurious fall
rates.

Among nursing process factors, falls with-
out employee assistance were a significant
factor contributing to injurious falls. This
finding is consistent with the findings from
previous studies.10,11 In a recent study of unas-
sisted inpatient falls, Staggs and colleagues11

found that falls without employee assistance
were 59% more likely to result in injuries than
falls with employee assistance. Similarly, the
findings from a study comparing inpatient
falls and injurious falls between teaching
and nonteaching hospitals suggested that
unassisted falls were significantly associated
with increased injuries resulting from falls in
both teaching and nonteaching hospitals.10

This finding has significant clinical impli-

cations. In patient care, nursing staff need
to monitor patients closely and provide
assistance as needed, given the association
between unassisted falls and injurious falls.

One important finding was that the risk of
injurious falls was expected to decrease by
2.5% when the percentage of patients at fall
risk increases by 10 percentage points on the
units. This finding indicates the importance
of nurses conducting fall risk assessment for
all inpatients and implementing fall protocols.
When a patient is identified at fall risk from
the assessment, nurses become more aware
of the patient’s fall risk and implement a fall
prevention protocol. Chari and colleagues8

found that patients were less likely to have
fractures from falls if they were evaluated for
fall risk upon admission. A previous study also
revealed that fall prevention protocol imple-
mentation was significantly associated with
increased assisted falls.11 This has significant
clinical implication since unassisted falls are
more likely to result in injuries.

Study limitations

The limitations of the study are similar to
the limitations of conducting secondary data
analyses. The generalizability of the study
findings may be limited because NDNQI
participating hospitals have characteristics
different from those of the nonparticipating
hospitals. NDNQI hospitals are mainly not-
for-profit hospitals with more, large Magnet
hospitals13 compared with nonparticipating
hospitals. Another limitation is that findings
may be not be generalizable to all adult
patients hospitalized because the study
sample included only adult patients who had
a fall while hospitalized. Patients might have
been identified at high risk for falls but did
not necessarily fall. In addition, the study did
not exclude repeat falls. One patient may
have multiple falls during the hospital stay,
but the data obtained from NDNQI did not
contain information on repeat falls.

CONCLUSIONS

This study examined the associations be-
tween injurious falls and multilevel structure,

Injurious Falls in Acute Care Hospitals 27

process, and patient factors in acute care
hospitals. Several hospital (teaching status)
and unit (surgical) organizational factors, as
well as nurse staffing (RNHPPD) and process
factors (fall risk, unassisted falls), were identi-
fied as significant factors contributing to inju-
rious falls. The study findings have important

implications for clinical practice and future re-
search. Researchers need to further examine
the impact of multilevel factors on injurious
falls. Hospital administrators and nurse man-
agers should consider nurse staffing and pro-
cess factors when planning and implementing
fall prevention programs.

REFERENCES

1. Oliver D, Healey F, Haines TP. Preventing falls and
fall-related injuries in hospitals. Clin Geriatr Med.
2010;26(4):645-692.

2. Zhao Y, Kim H. Older adult inpatient falls in acute
care hospitals: intrinsic, extrinsic and environmental
factors. J Gerontol Nurs. 2015;41(7):29-43.

3. Wong CA, Recktenwald AJ, Jones ML, Waterman BM,
Bollini ML, Dunagan W. The cost of serious fall-related
injuries at three Midwestern hospitals. Jt Comm J
Qual Patient Saf. 2011;37(2):81-87.

4. Cameron ID, Gillespie LD, Robertson MC, et al.
Interventions for preventing falls in older peo-
ple in care facilities and hospitals. Cochrane
Database Syst Rev. 2012;12:CD005465. doi:10.1002/
14651858.CD005465.pub2.

5. US Department of Health and Human Services.
Healthy People 2020: Improving the Health of Amer-
icans. Washington, DC: US Government Printing Of-
fice; 2010.

6. Centers for Medicare & Medicaid Services. Medicare
program: changes to the hospital inpatient prospec-
tive payment systems and fiscal year 2009 rates. Fed
Regist. 2008;73(16):48433-49084.

7. Bouldin ELD, Andresen EM, Dunton NE, et al. Falls
among adult patients hospitalized in the United States:
prevalence and trends. J Patient Saf. 2013;9(1):13-17.

8. Chari S, McRae P, Varghese P, Ferrar K, Haines TP. Pre-
dictors of fracture from falls reported in hospital and
residential care facilities: a cross-sectional study. BMJ
Open. 2013;3. doi:10.1136/bmjopen-2013-002948.

9. Williams T, Szekendi M, Thomas S. An anal-
ysis of patient falls and fall prevention pro-
grams across academic medical centers. J Nurs
Care Qual. 2014;29(1):19-29. doi:10.1097/NCQ
.0b013e3182a0cd19.

10. Krauss M, Nguyen S, Dunagan C, et al. Circum-
stances of patient falls and injuries in 9 hospitals in a
Midwestern healthcare system. Infect Control Hosp
Epidemiol. 2007;28(3):544-550.

11. Staggs VS, Mion LC, Shorr RI. Assisted and unassisted
falls: different events, different outcomes, different
implications for quality of hospital care. Jt Comm J
Qual Patient Saf. 2014;40(8):358-364.

12. Dunton N, Gajewski B, Taunton RL, Moore J. Nurse
staffing and patient falls on acute care hospital units.
Nurs Outlook. 2004;52(1):53-59.

13. Dunton N, Gajewski B, Klaus S, Pierson B. The rela-
tionship of nursing workforce characteristics to pa-
tient outcomes. Online J Issues Nurs. 2007;12(3).
Article 3. doi:10.3912/OJIN.Vol12No03Man03.

14. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt
TJ. The association of registered nurse staffing levels
and patient outcomes. Systematic review and meta-
analysis. Med Care. 2007;45(12):1195-1204.

15. Lake ET, Cheung RB. Are patient falls and pressure
ulcers sensitive to nurse staffing? West J Nurs Res.
2006;28(6):654-677.

16. Berzlanovich AM, Schöpfer J, Keil W. Deaths due
to physical restraint. Dtsch Arztebl Int. 2012;109(3):
27-32.

17. Tzeng H, Yin C. Physical restraint use rate and total
fall and injurious fall rates: an exploratory study in
two US acute care hospitals. Open J Nurs. 2012;2:
170-175.

18. Coyle YM, Battles JB. Using antecedents of medical
care to develop valid quality of care measures. Int J
Qual Health C. 1999;11(1):5-12.

19. Donabedian A. The quality of care: how can it be
assessed? JAMA. 1988;260:1743-1748.

20. Garrard L, Boyle DK, Simon M, Dunton N, Gajewski
B. Reliability and validity of the NDNQI R© injury falls
measure. West J Nurs Res. 2016;38(1):111-128.

21. National Quality Forum. NQF-endorsed measures for
patient safety. http://www.qualityforum.org. Pub-
lished 2015. Accessed March 2, 2016.

22. National Database of Nursing Quality Indicators
(NDNQI R©). Guidelines for Data Collection and Sub-
mission on Patient Falls Indicator: Inpatient and
Ambulatory Areas. Kansas City, KS: Press Ganey As-
sociates Inc; 2014.

23. Rabe-Hesketh S, Skrondal A. Multilevel and Longitu-
dinal Modeling Using Stata. 3rd ed. College Station,
TX: Stata Press; 2012.

24. Pingleton S, Davis K, Dickler R. Characteristics of
quality and patient safety curricula in major teaching
hospitals. Am J Med Qual. 2010;25(4):305-311.

http://www.qualityforum.org

28 JOURNAL OF NURSING CARE QUALITY/JANUARY–MARCH 2018

25. Hall LM, Doran D, Sidani S, Pink L. Teaching and com-
munity hospital work environments. West J Nurs Res.
2006;28(6):710-725.

26. Aiken LH, Sloane DM, Clarke S, et al. Importance
of work environments on hospital outcomes in nine
countries. Int J Qual Health Care. 2011;23(4):357-
364.

27. Aiken LH, Sermeus W, Van den Heede K, et al. Pa-
tient safety, satisfaction, and quality of hospital care:
cross sectional surveys of nurses and patients in
12 countries in Europe and the United States. BMJ.
2012;344:e1717.

28. Lake ET, Shang J, Klaus S, Dunton N. Patient falls:
association with hospital Magnet R© status and nursing
unit staffing. Res Nurs Health. 2010;33(5):413-425.

29. He J, Dunton N, Staggs V. Unit-level time trends
in inpatient fall rates of US hospitals. Med Care.
2012;50(9):800-807.

30. Feldman LS, Lee L, Fiore J. What outcomes are
important in the assessment of Enhanced Recov-

ery After Surgery (ERAS) pathways? Can J Anaesth.
2015;62(2):120-130.

31. Watson DS. The benefits of enhanced recovery path-
ways in perioperative care. AORN J. 2015;102(5):
464-467.

32. Jans O, Bundgaard-Nielsen M, Solgaard S, Johansson
PI, Kehlet H. Orthostatic intolerance during early mo-
bilization after fast-track hip arthroplasty. Br J Anes-
thesiol. 2012;108(3):436-443.

33. Emaminia A, Corcoran PC, Siegenthaler MP, et al. The
universal bed model for patient care improves out-
come and lowers cost in cardiac surgery. J Thorac
Cardiovasc Surg. 2012;143(2):475-481.

34. Hennon MW, Kothari A, Maloney JD, Weigel T. Imple-
mentation of an Acuity Adaptable Patient Care Unit is
associated with improved outcomes after major pul-
monary resections. J Surg Res. 2011;170(1):e17-e21.

35. Venditti A. Patient-centered care: impacting qual-
ity with the acuity adaptable model. Nurs Manage.
2015;46(7):36-42.

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