What is the most important intervention when trying to prevent a patient from falling in their room

1. He J, Dunton N, Staggs V. Unit-level time trends in inpatient fall rates of US hospitals. Med Care 2012;50:801–807. [PubMed] [Google Scholar]

2. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:390–396. [PubMed] [Google Scholar]

3. Ganz DA, Huang C, Saliba D, Shier V. Preventing falls in hospitals: a toolkit for improving quality of care (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI Institute under Contract No. HHSA290201000017I TO #1.). Rockville, MD: Agency for Healthcare Research and Quality; 2013. [Google Scholar]

4. Hempel S, Newberry S, Wang Z, et al. Review of the Evidence on Falls Prevention in Hospitals: Task 4 Final Report. Santa Monica, Calif.: RAND Corporation, WR-907-AHRQ2012: http://www.rand.org/pubs/working_papers/WR907. Accessed September 21, 2014. [Google Scholar]

5. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med 2010;26:645–692. [PubMed] [Google Scholar]

6. Fall Currie L. and Prevention Injury. In: Hughes RG, ed. Patient safety and quality: an evidence-based handbook for nurses (Prepared with support from the Robert Wood Johnson Foundation) AHRQ Publication NO.08-0043. Rockville, MD: Agency for Healthcare Research and Quality; 2008. [Google Scholar]

7. Agostini JV, Baker DI, Bogardus ST. Chapter 26. Prevention of Falls in Hospitalized and Institutionalized Older People. Making Health Care Safer: A Critical Analysis of Patient Safety Practices File Inventory, Evidence Report/Technology Assessment Number 43. AHRQ Publication No. 01-E058. Rockville, MD: Agency for Healthcare Research and Quality; 2001:281–299. [Google Scholar]

8. Morse JM. Enhancing the safety of hospitalization by reducing patient falls. Am J Infect Control 2002;30:376–380. [PubMed] [Google Scholar]

9. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002;18:141–158. [PubMed] [Google Scholar]

10. The Joint Commission. Sentinel Event Data Root Causes by Event Type 2004–2012. http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_04_4Q2012.pdf. Published 2012. Accessed October 8, 2014. [Google Scholar]

11. Gulwadi GB, Calkins MP. The impact of healthcare environmental design on patient falls. Concord, CA: Center for Healthcare Design; 2008. [Google Scholar]

12. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med 2009;360:2390–2393. [PubMed] [Google Scholar]

13. Goldsack J, Cunningham J, Mascioli S. Patient falls: searching for the elusive “silver bullet”. Nursing 2014;44:61–62. [PubMed] [Google Scholar]

14. (1) Prevention of falls and fall injuries in the older adult. (2) Prevention of falls and fall injuries in the older adult 2011 supplement. National Guideline Clearinghouse. 2011. https://rnao.ca/sites/rnaoca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf. Accessed August 6, 2018.

15. Fall prevention. In: Evidence-based geriatric nursing protocols for best practice. National Guideline Clearinghouse. 2013. https://www.guidelinecentral.com/summaries/fall-prevention-in-evidence-based-geriatric-nursing-protocols-for-best-practice/. Accessed August 6, 2018. [Google Scholar]

16. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals. https://www.safetyandquality.gov.au/wp-content/uploads/2009/01/Guidelines-HOSP.pdf. [Google Scholar]

17. Haines TP, Waldron NG. Translation of falls prevention knowledge into action in hospitals: what should be translated and how should it be done? J Safety Res 2011;42:431–442. [PubMed] [Google Scholar]

18. Lopez KD, Gerling GJ, Cary MP, Kanak MF. Cognitive work analysis to evaluate the problem of patient falls in an inpatient setting. J Am Med Inform Assoc 2010;17:313–321. [PMC free article] [PubMed] [Google Scholar]

19. Graham KC, Cvach M. Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms. Am J Crit Care 2010;19:28–34; [PubMed] [Google Scholar]

20. Lea E, Andrews S, Hill K, et al. Beyond the ‘tick and flick’: facilitating best practice falls prevention through an action research approach. J Clin Nurs 2012;21:1896–1905. [PubMed] [Google Scholar]

21. Fiore LD, Lavori PW. Integrating Randomized Comparative Effectiveness Research with Patient Care. N Engl J Med 2016;374:2152–2158. [PubMed] [Google Scholar]

22. Pronovost P, Wachter R. Proposed standards for quality improvement research and publication: one step forward and two steps back. Qual Saf Health Care 2006;15:152–153. [PMC free article] [PubMed] [Google Scholar]

23. Hempel S, Newberry S, Wang Z, et al. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. J Am Geriatr Soc 2013;61:483–494. [PMC free article] [PubMed] [Google Scholar]

24. Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised trial: rationale, design, analysis, and reporting. BMJ 2015;350:h391. [PubMed] [Google Scholar]

25. Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect of Medicare’s nonpayment for Hospital-Acquired Conditions: lessons for future policy. JAMA Intern Med 2015;175:347–354. [PMC free article] [PubMed] [Google Scholar]

26. Soumerai SB, Ceccarelli R, Koppel R. False Dichotomies and Health Policy Research Designs: Randomized Trials Are Not Always the Answer. J Gen Intern Med 2017;32:204–209. [PMC free article] [PubMed] [Google Scholar]

27. Aranda-Gallardo M, Morales-Asencio JM, Canca-Sanchez JC, et al. Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC Health Serv Res 2013;13:122. [PMC free article] [PubMed] [Google Scholar]

28. da Costa BR, Rutjes AW, Mendy A, Freund-Heritage R, Vieira ER. Can falls risk prediction tools correctly identify fall-prone elderly rehabilitation inpatients? A systematic review and meta-analysis. PLoS One 2012;7:e41061. [PMC free article] [PubMed] [Google Scholar]

29. Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing 2004;33:122–130. [PubMed] [Google Scholar]

30. Haines TP, Hill K, Walsh W, Osborne R. Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis. J Gerontol A Biol Sci Med Sci 2007;62:664–672. [PubMed] [Google Scholar]

31. Matarese M, Ivziku D, Bartolozzi F, Piredda M, De Marinis MG. Systematic review of fall risk screening tools for older patients in acute hospitals. J Adv Nurs 2015;71:1198–1209. [PubMed] [Google Scholar]

32. National Institute for Health and Care Excellence. Assessment and prevention of falls in older people. NICE clinical guideline 161. https://www.nice.org.uk/guidance/cg161/evidence/full-guideline-pdf-190033741. Published June 2013. Accessed August 6, 2018. [Google Scholar]

33. Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA 2010;304:1912–1918. [PMC free article] [PubMed] [Google Scholar]

34. Oliver D Falls risk-prediction tools for hospital inpatients. Time to put them to bed? Age Ageing 2008;37:248–250. [PubMed] [Google Scholar]

35. Wong Shee A, Phillips B, Hill K, Dodd K. Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward. J Nurs Care Qual 2014;29:253–262. [PubMed] [Google Scholar]

36. Centers for Medicare & Medicaid Services. State Operations Manual: Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 173, 11-22-17). https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html. Published June 12, 2018 Accessed July 5, 2017. [Google Scholar]

37. Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Ann Intern Med 2012;157:692–699. [PMC free article] [PubMed] [Google Scholar]

38. Sahota O, Drummond A, Kendrick D, et al. REFINE (REducing Falls in In-patieNt Elderly) using bed and bedside chair pressure sensors linked to radio-pagers in acute hospital care: a randomised controlled trial. Age Ageing 2014;43:247–253. [PMC free article] [PubMed] [Google Scholar]

39. Shever LL, Titler MG, Mackin ML, Kueny A. Fall prevention practices in adult medical-surgical nursing units described by nurse managers. West J Nurs Res 2011;33:385–397. [PubMed] [Google Scholar]

40. The Joint Commission 2014 Hospital National Patient Safety Goals. Goal 6: Reduce the harm associated with clinical alarm systems. 2013. http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf. Accessed December 13, 2014. [Google Scholar]

41. Wolf KH, Hetzer K, zu Schwabedissen HM, Wiese B, Marschollek M. Development and pilot study of a bed-exit alarm based on a body-worn accelerometer. Z Gerontol Geriatr 2013;46:727–733. [PubMed] [Google Scholar]

42. Balaguera HU, Wise D, Ng CY, et al. Using a Medical Intranet of Things System to Prevent Bed Falls in an Acute Care Hospital: A Pilot Study. J Med Internet Res 2017;19:e150. [PMC free article] [PubMed] [Google Scholar]

43. Lang CE. Do sitters prevent falls? A review of the literature. J Gerontol Nurs 2014;40:24–33; [PubMed] [Google Scholar]

44. Wood VJ, Vindrola-Padros C, Swart N, et al. One to one specialling and sitters in acute care hospitals: A scoping review. Int J Nurs Stud 2018;84:61–77. [PubMed] [Google Scholar]

45. Spiva L, Feiner T, Jones D, Hunter D, Petefish J, VanBrackle L. An evaluation of a sitter reduction program intervention. J Nurs Care Qual 2012;27:341–345. [PubMed] [Google Scholar]

46. Rochefort CM, Ward L, Ritchie JA, Girard N, Tamblyn RM. Registered nurses’ job demands in relation to sitter use: nested case-control study. Nurs Res 2011;60:221–230. [PubMed] [Google Scholar]

47. Tzeng HM, Yin CY, Grunawalt J. Effective assessment of use of sitters by nurses in inpatient care settings. J Adv Nurs 2008;64:176–183. [PubMed] [Google Scholar]

48. Boswell DJ, Ramsey J, Smith MA, Wagers B. The cost-effectiveness of a patient-sitter program in an acute care hospital: a test of the impact of sitters on the incidence of falls and patient satisfaction. Qual Manag Health Care 2001;10:10–16. [PubMed] [Google Scholar]

49. Feil M, Wallace SC. The Use of Patient Sitters to Reduce Falls: Best Practices. Pa Patient Saf Advis 2014;11:8–14. [Google Scholar]

50. Salamon L, Lennon M. Decreasing companion usage without negatively affecting patient outcomes: a performance improvement project. Medsurg Nurs 2003;12:230–236; [PubMed] [Google Scholar]

51. Rausch DL, Bjorklund P. Decreasing the costs of constant observation. J Nurs Adm 2010;40:75–81. [PubMed] [Google Scholar]

52. Bock TJ. A solution to sitters that won’t fall short. Nurs Manage 2017;48:38–44. [PubMed] [Google Scholar]

53. Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit Care 2009;18:581–584. [PubMed] [Google Scholar]

54. Mitchell MD, Lavenberg JG, Trotta RL, Umscheid CA. Hourly rounding to improve nursing responsiveness: a systematic review. J Nurs Adm 2014;44:462–472. [PMC free article] [PubMed] [Google Scholar]

55. Toole N, Meluskey T, Hall N. A systematic review: barriers to hourly rounding. J Nurs Manag 2016;24:283–290. [PubMed] [Google Scholar]

56. Deitrick LM, Baker K, Paxton H, Flores M, Swavely D. Hourly rounding: challenges with implementation of an evidence-based process. J Nurs Care Qual 2012;27:13–19. [PubMed] [Google Scholar]

57. Christiansen A, Coventry L, Graham R, Jacob E, Twigg D, Whitehead L. Intentional rounding in acute adult healthcare settings: A systematic mixed-method review. J Clin Nurs 2018;27:1759–1792. [PubMed] [Google Scholar]

58. Haines TP, Hill KD, Bennell KL, Osborne RH. Patient education to prevent falls in subacute care. Clin Rehabil 2006;20:970–979. [PubMed] [Google Scholar]

59. Hill AM, McPhail SM, Waldron N, et al. Fall rates in hospital rehabilitation units after individualised patient and staff education programmes: a pragmatic, stepped-wedge, cluster-randomised controlled trial. Lancet 2015;385:2592–2599. [PubMed] [Google Scholar]

60. Evans D, Hodgkinson B, Lambert L, Wood J. Falls risk factors in the hospital setting: a systematic review. Int J Nurs Pract 2001;7:38–45. [PubMed] [Google Scholar]

61. Donald IP, Pitt K, Armstrong E, Shuttleworth H. Preventing falls on an elderly care rehabilitation ward. Clin Rehabil 2000;14:178–185. [PubMed] [Google Scholar]

62. Haines TP, Bell RA, Varghese PN. Pragmatic, cluster randomized trial of a policy to introduce low-low beds to hospital wards for the prevention of falls and fall injuries. J Am Geriatr Soc 2010;58:435–441. [PubMed] [Google Scholar]

63. Mills PB, Neily J, Luan D, Stalhandske E, Weeks WB. Using aggregate root cause analysis to reduce falls. Jt Comm J Qual Patient Saf 2005;31:21–31. [PubMed] [Google Scholar]

64. Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting. J Gen Intern Med 2004;19:732–739. [PMC free article] [PubMed] [Google Scholar]

65. Taylor E, Hignett S. The SCOPE of Hospital Falls: A Systematic Mixed Studies Review. HERD 2016;9:86–109. [PubMed] [Google Scholar]

66. U.S. Food and Drug Administration. Class 1 Device Recall Vail 1000 Enclosed Bed System. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfres/res.cfm?id=39028. Published June 5, 2005 Accessed August 6, 2018. [Google Scholar]

67. Vassallo M, Wilkinson C, Stockdale R, Malik N, Baker R, Allen S. Attitudes to restraint for the prevention of falls in hospital. Gerontology 2005;51:66–70. [PubMed] [Google Scholar]

68. Miles SH, Irvine P. Deaths caused by physical restraints. Gerontologist 1992;32:762–766. [PubMed] [Google Scholar]

69. Mion LC, Minnick A, Palmer R. Physical restraint use in the hospital setting: unresolved issues and directions for research. Milbank Q 1996;74:411–433. [PubMed] [Google Scholar]

70. Shorr RI, Guillen MK, Rosenblatt LC, Walker K, Caudle CE, Kritchevsky SB. Restraint use, restraint orders, and the risk of falls in hospitalized patients. J Am Geriatr Soc 2002;50:526–529. [PubMed] [Google Scholar]

71. Frank C, Hodgetts G, Puxty J. Safety and efficacy of physical restraints for the elderly. Review of the evidence. Can Fam Physician 1996;42:2402–2409. [PMC free article] [PubMed] [Google Scholar]

72. Marks W Physical restraints in the practice of medicine. Current concepts. Arch Intern Med 1992;152:2203–2206. [PubMed] [Google Scholar]

73. Minnick AF, Fogg L, Mion LC, Catrambone C, Johnson ME. Resource clusters and variation in physical restraint use. J Nurs Scholarsh 2007;39:363–370. [PubMed] [Google Scholar]

74. Heinze C, Dassen T, Grittner U. Use of physical restraints in nursing homes and hospitals and related factors: a cross-sectional study. J Clin Nurs 2012;21:1033–1040. [PubMed] [Google Scholar]

75. 42 CFR 482. Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients’ Rights: Final Rule. Federal Register. Vol 712006:71378–71428. [PubMed] [Google Scholar]

76. The Joint Commission. Hospital Accreditation Standards (HAS) 2007. Oakbrook Terrace, IL: JCAHO; 2006. [Google Scholar]

77. Chari S, Haines T, Varghese P, Economidis A. Are non-slip socks really ‘non-slip’? An analysis of slip resistance. BMC Geriatr 2009;9:39. [PMC free article] [PubMed] [Google Scholar]

78. Hartung B, Lalonde M. The use of non-slip socks to prevent falls among hospitalized older adults: A literature review. Geriatr Nurs 2017. [PubMed] [Google Scholar]

79. Mahida N, Boswell T. Non-slip socks: a potential reservoir for transmitting multidrug-resistant organisms in hospitals? J Hosp Infect 2016;94:273–275. [PubMed] [Google Scholar]

80. Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ 2004;328:676. [PMC free article] [PubMed] [Google Scholar]

81. Healey F, Monro A, Cockram A, Adams V, Heseltine D. Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age Ageing 2004;33:390–395. [PubMed] [Google Scholar]

82. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008;336:758–760. [PMC free article] [PubMed] [Google Scholar]

83. Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ 2016;352:h6781. [PMC free article] [PubMed] [Google Scholar]

84. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2012;12:CD005465. [PubMed] [Google Scholar]

85. DiBardino D, Cohen ER, Didwania A. Meta-analysis: multidisciplinary fall prevention strategies in the acute care inpatient population. J Hosp Med 2012;7:497–503. [PubMed] [Google Scholar]