Implementing and sustaining evidence-based practices in long-term care.

Falls Prevention and Management

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    Preventing Falls and Reducing Injury from Falls (3rd ed.) replaces the RNAO (2011) BPG Prevention of Falls and Fall Injuries in the Older Adult, which was originally published in 2002 and then revised in 2005 and 2011. Whereas previous editions focused on older adults in hospital and long-term-care settings, the scope of this third edition has been expanded to include in all adults (>18 years) at risk for falls and receiving care from nurses and other health-care providers across the health-care continuum, including those living in the community.

    The purpose of this guideline is to outline evidence-based approaches for preventing falls and reducing fall injuries for adults. Recommendations are provided at the following three levels:

    • Practice recommendations are directed primarily toward nurses who provide direct clinical care to adults at risk for falls across the continuum of care, including (but not limited to): primary care, home care, hospital care, and long-term care settings. The secondary audience of the practice recommendations includes other members of the interprofessional team who collaborate with nurses to provide comprehensive care. All of the recommendations are applicable to the scope of practice of registered nurses and nurse practitioners (general and extended classes); however, many are also applicable to other health-care providers.
    • Education recommendations are directed at individuals and organizations responsible for the education of healthcare providers, such as educators, quality improvement teams, managers, administrators, academic institutions, and professional organizations.
    • Organization and policy recommendations are directed at those managers, administrators, and policy-makers responsible for developing policy or securing the supports required within health-care organizations that enable the implementation of best practices. For optimal effectiveness, recommendations in these three areas should be implemented together.
    Registered Nurses’ Association of Ontario.  (2017).  RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author.

     This work is funded by the Ontario Ministry of Health and Long-Term Care

    http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries

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    Falls Gap Analysis

    An organizational assessment tool to assist with implementation and evaluation of the RNAO Prevention of Falls and Injury from Falls by comparing current practice to evidence-based practice.

    Registered Nurses' Association of Ontario's Long-Term Care Best Practices Program, Toronto, ON, Canada. September 2017.

     

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    This document contains sample program objectives, policy, procedures, staff training materials and tools related to fall prevention. (Member login is not required. The documents may be accessed by scrolling to the bottom of page.)

    Ontario Association of Non-profit homes and services for seniors. (2011). OANHSS LTCHA Implementation Member Support Project. Fall Prevention and Management Program: Policy, Procedures and Training Package.

    Copyright 2011.

     

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    Appendix F - provides a summary of related approaches and tools for assessing fall risk. The tools are categorized as follows: gait and balance; general fall risk and fear of falls. It is important for the organization to review the findings to support selection of tools for settings and population(s) served noting that other tools are available that address specific risk factors.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix F of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.92-97.)

     

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    This is an easy to read 2-page information sheet dispelling some of the myths with bone health. 

    Best practice in LTC initiative Central South and the Long-Term Care Resource Central Hamilton. (January 2008). BP Blogger: Myth Busting: The Bone Issue, 3(1). Retrieved from http://www.rgpc.ca/

     

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    This Article evaluates the Care Rounds initiative and highlights its effectiveness in ensuring patient safety.

    Queen Elizabeth Hospital. University Hospitals Birmingham. (November 2012). Care Round initiative supports patient safety. Retrieved from http://www.uhb.nhs.uk/news/care-round-initiative-supports-patient-safety.htm

     

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    AThis table lists common components of universal falls precautions that health care organizations can determine which precautions are applicable to their setting.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix K of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.113)

     

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    Table 18 summarizes different approaches to exercise and physical training interventions with varying degrees of effectiveness.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix H of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.104-107.)

     

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    The tool reviews the extrinsic and intrinsic risk factors for falls, as well as stratgeies for the development of a fall intervention program.

    Iowa Geriatric Education Center and University of Iowa. (n.d.). Fall Prevention. Retrieved from: http://www.healthcare.uiowa.edu/IGEC/publications/infoconnect

     

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    Fallsloop is an online communication platform for the virtual Falls community of practice. Practitioners, caregivers, researchers, older adult groups and policy planners working for the health and care of older adults come together to exchange information on prevention of falls and fall-related injuries, to support and learn from one another and to develop

    The Ontario Neurotrauma Foundation (n.d.) Fall Prevention Community of Practice Loop. Retrieved from www.fallsloop.com
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    A fall prevention toolkit for planning events, information on evidence informed and evaluated fall prevention programs, resources and tools for practitioners and promotional materials for organizations.

    Fall Prevention Month. (n.d.). Fall prevention month toolkit. Retrieved from http://fallpreventionmonth.ca/ 

     

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    Example of a form for documentation from St Joseph’s Healthcare Hamilton on falls debriefing and action plan.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix J: Example: Falls debriefing and action plan from St. Joseph's Healthcare Hamilton (Ontario, Canada) of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.). Toronto, ON: Author. (p.111-112.)

     

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    The Centre for Effective Practice developed a discussion guide and caregiver supplement which includes topics of assessment of fall prevention and prevention in relation to associated co-morbidities. This guide includes references to available relevant tools and services.

    Centre For Effective Practice. (2016). Falls Prevention Discussion Guide. Retrieved from https://cep.health/clinical-products/falls-preventon/#pc_page_1032

     

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    This guide provides general information on falls prevention in different settings. Falls prevention strategies, best practices, and interventions are discussed.

    Source: http://www.mississaugahaltonlhin.on.ca/Search.aspx?search=fall prevention resource guide  

    Mississauga Halton LHIN. Falls Prevention Resource Guide. 2008. Retrieved from Website: http://www.mississaugahaltonlhin.on.ca/

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    A flow chart that summarizes the steps, context, and considerations in falls prevention and injury reduction.

    Registered Nurses’ Association of Ontario.  (2017).  RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.24)
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    This online eLearning module provides the learner background information about causes and risk factors for falls. Reviews both extrinsic and intrinsic risk factors for falls, as well as the interdisipdisciplinary health care team that can be utilized to prevent falls in the geriatric population. Registration is required to access the eLearning Modules.

    Reference: Content Developed by GiiC toolkit Developed by the RGPs of Ontario, (nd), Frailty e-Learning Modules, Retrieved February 29, 2016, http://www.regionalhealthprogramsww.com/frailtymodules/register/

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    This handout describes why freezing occurs in Parkinson disease and how it increases a resident’s chances of falling. It provides 14 care-planning tips to help prevent freezing. Can be used for family or resident education on fall prevention as well as staff educational material.

    Reference: Parkinson Society Canada. (2015). Factsheets: Freezing. Retrieved from http://www.parkinson.ca/wp-content/uploads/2017/09/Freezing.pdf 

    Source: Pacific Parkinson’s Research Centre, University of British Columbia, Vancouver, BC

    Based on a fact sheet developed by Parkinson Society BC: reprinted with permission.

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    Example signage of Intentional Hourly Rounding Poster from Fraser Health, British Columbia, Canada.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix K of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.). Toronto, ON: Author. (p.115)

     

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    Table-14, 15, 16 and 17 summarize evidence from the reviewed literature on specific fall prevention and injury reduction interventions. They are organized according to the benefit of the interventions. Health-care providers use clinical judgment to determine if interventions apply to their settings.

    • Table 14: interventions with strong evidence of benefit.
    • Table 15: interventions that have potential benefit.
    • Table 16: interventions with mixed findings.
    • Table 17: interventions with insufficient evidence of benefit.
    Registered Nurses’ Association of Ontario.  (2017).  Appendix G of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.98-103)

     

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    A sample Jeopardy game illustrates a fun way to evaluate learning related to falls prevention and management. Source: Registered Nurses' Association of Ontario's Long-Term Care Best Practices Program, Toronto, ON. July 2017.

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    Tables 10, 11 and 12 list of risk factors that include fall risk factors, health conditions associated with increased risk of falls, and factors associated with increased risk of falls injury.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix E of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.88-91.)

     

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    LTC Series - Personal Support Worker: How to Safely Transfer In and Out of Bed is a two minute Osteoporosis Canada video discusses and demonstrates how to safely transfer residents in and out of bed.

    Osteoporosis Canada. [GERAS Centre]. (2018, Feb 8). LTC Series - Personal Support Worker: How to Safely Transfer Out/In Bed [Video]. YouTube. https://www.youtube.com/watch?v=3l93LkyHyLY&t=5s

     

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    LTC Series - Personal Support Worker: Introduction is a two minute video introduces Personal Support Workers to the three part series of Osteoporosis Canada videos that discusses and demonstrates how to safely transfer residents in and out of bed, how to properly position residents for sitting, and how to help residents practice sit to stand exercises.

    Osteoporosis Canada. [GERAS Centre]. (2018, Feb 8). LTC Series - Personal Support Worker: Introduction [Video]. YouTube. https://www.youtube.com/watch?v=ZYkEnNdlegI

     

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    LTC Series - Personal Support Worker: Practicing Sit to Stands Daily is a two and a half minute Osteoporosis Canada video discusses and demonstrates how to do daily sit to stand exercises for long term care residents.

    Osteoporosis Canada. [GERAS Centre]. (2018, Feb 8). LTC Series - Personal Support Worker: IPracticing Sit to Stands Daily [Video]. YouTube. https://www.youtube.com/watch?v=yUWg3x6LUgU

     

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    LTC Series - Personal Support Worker: Proper Positioning for Sitting is a one and a half minute Osteoporosis Canada video discusses and demonstrates how to properly position residents for sitting.

    Osteoporosis Canada. [GERAS Centre]. (2018, Feb 8). LTC Series - Personal Support Worker: Proper positioning for sitting. [Video]. YouTube. https://www.youtube.com/watch?v=ssxzMpcCRDM

     

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    Table 19 provides a list of medication resources for use in fall prevention and reduction of injury from falls.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix I of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.108.)

     

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    This scale requires systematic, reliable assessment of a client’s fall risk factors upon admission, after a fall, with a change in status, and at discharge or transfer to a new setting.

    Morse, J.M., Morse, R., & Tylko, S. J. (1989). National Center for Patient Safety (NCPS).

    http://www.rgp.toronto.on.ca/torontobestpractice/Morsefallscale.pdf

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    This website is a source of information created for Ontario Long-term care homes regarding osteoporosis and fracture prevention. It includes resources, tools and the recommendations for preventing fractures in long-term care.

    Source: : http://gerascentre.ca 

    Reference: Geriatric Education and Research in Aging Sciences (GERAS). Osteoporosis Long-Term Care. Retrieved from http://gerascentre.osteoporosislongtermcare.ca/

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    Table 20 is a description of resources available to support post fall assessments.

    Reference: Registered Nurses’ Association of Ontario. (2017). Preventing Falls and Reducing Injury from Falls (3rd ed.). Toronto, ON

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    The collaborative interprofessional resource manual provides a range of tools related to falls prevention in long-term care.

    Bridges to Care Project (Healthforce Ontario 2009-10) Preventing Falls and Injuries in Long Term Care. Kingston, ON: The Centre for Studies in Aging & Health (CSAH) at Providence Care. Website: http://www.sagelink.ca/

     

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    Getting Started Kit is an updated version of June 2013 with measures revised April 2015. It is a resource for interdisciplinary teams to implement fall prevention programs in an organization to reduce falls and injuries. It includes screening and assessment tools, interventions, audit tools and guidance to use quality improvement methods to integrate evidence in practice.

    Reference: Safer Healthcare Now, June 2013 (measures revised 2015). Reducing falls and injuries from falls: getting started kit. Retrieved from http://www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/Falls%20Getting%20Started%20Kit.pdf

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    Canadian Patient Safety Institute website contains tools and resources on Reducing Falls and Injury from Falls: Getting Started Kit. June 2013 (Measures revised April 2015). It contains clinical information on reducing falls and injuries from falls; and information on making improvements. Icons and resources to successfully implement interventions in an organization on best practices related to falls

    Reference link and resource link to: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx 

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    For the purpose of this document, Interprofessional is defined as: Multiple health disciplines with diverse knowledge and skills who share an integrated set of goals and who utilize interdependent collaboration that involves communication, sharing of knowledge and coordination of services to provide services to patients/clients and their care-giving systems.

    This best practice guideline, Developing and Sustaining Interprofessional Health Care: Optimizing patients/clients, organizational, and system outcomes is intended to foster healthy work environments. The focus in developing this guideline was identifying attributes of interprofessional care that will optimize quality outcomes for patients/clients, providers, teams, the organization and the system.

    This guideline identifies best practices to enable, enhance and sustain teamwork and interprofessional collaboration, and to enhance positive outcomes for patients/clients, systems and organizations. It is based on the best available evidence; where evidence was limited, the recommendations were based on the consensus of expert opinion.

    Registered Nurses’ Association of Ontario. (2013). Developing and Sustaining Interprofessional health care. Toronto, ON: http://rnao.ca/bpg/guidelines/interprofessional-team-work-healthcare

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    The Promoting Continence Using Prompted Voiding guideline can be used for implementation of a treatment program of prompted voiding for older adults with urinary incontinence. The goals of prompted voiding are to: •Reduce the frequency and severity of urinary incontinence episodes; •Prevent the complications associated with urinary incontinence; and •Improve quality of life.

    Revised: 2005 Revised: 2011

    Registered Nurses’ Association of Ontario. Promoting Continence Using Prompted Voiding Best Practice Guideline. (2011). Toronto, ON: Author. Retrieved from: http://rnao.ca/bpg/guidelines/promoting-continence-using-prompted-voiding  

    This work is funded by the Ontario Ministry of Health and Long-Term Care.

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    Nurses require knowledge and evidence on the use of alternative approaches to the use of restraints. The promotion of safe evidence based care is the goal to prevent the untoward incidents from the use of restraints. This guideline offers nurses a model which will help them to examine their approach to the use of restraints within their practice.

    Registered Nurses’ Association of Ontario. (2012). Promoting Safety: Alternative Approaches to the Use of Restraints. Toronto, ON, Canada: Author. Retrieved from http://rnao.ca/bpg/guidelines/promoting-safety-alternative-approaches-use-restraints.

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    Seniors Health Knowledge Network (SHKN) is an Ontario wide Community of Practice (CoP) on Fall prevention in seniors. It is a platform for sharing knowledge, research, best practices and resources for multiple stakeholders including frontline health care workers, seniors, caregivers, policy makers, planners and researchers.

    Retrieved from http://www.shrtn.on.ca

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    Le but de la présente ligne directrice est de promouvoir les pratiques fondées sur des données probantes, qui sont associées aux soins axés sur les besoins de la personne et de la famille, et d'aider les infirmières et d'autres fournisseurs de soins de santé à acquérir les connaissances et les compétences nécessaires pour améliorer leur pratique de ces soins. Les recommandations aideront les infirmières et d'autres fournisseurs de soins de santé à obtenir le savoir requis pour collaborer et établir des relations habilitantes avec des personnes et leur famille qui font appel aux services de santé, afin d'optimiser la santé et le bien-être au cours de leur vie. Cette approche fondée sur des données probantes, et combinée à une perspective qui reconnaît la place de la personne au centre des soins de santé, permettra d'améliorer l'expérience de cette personne et sa satisfaction à l'égard des soins et des services offerts par le système de santé. Elle s'applique à tous les domaines de la pratique des soins infirmiers, y compris les secteurs clinique, administratif et éducatif.

    Cette ligne directrice recommande des pratiques exemplaires dans trois domaines principaux : ■ Les recommandations au sujet des pratiques exemplaires ont été rédigées principalement à l'intention des infirmières et d'autres fournisseurs de soins de santé dans l'équipe interprofessionnelle qui offre des soins directs à des personnes dans les milieux de soins du système de santé (p. ex., soins actifs, soins de longue durée et soins à domicile) et dans la collectivité (p. ex., soins primaires, équipes de santé familiale et santé publique). ■ Les recommandations en matière d'éducation s'adressent à ceux qui sont responsables de la formation du personnel et des étudiants, tels que les éducateurs, les équipes d'amélioration de la qualité, les gestionnaires, les administrateurs ainsi que les établissements d'enseignement universitaire et professionnel. ■ Les recommandations sur le système, l'organisation et la politique s'appliquent à divers publics selon le type de recommandation. Les publics comprennent les gestionnaires, les administrateurs, les décideurs, les organismes de réglementation en soins infirmiers, les établissements d'enseignement et les organismes gouvernementaux. Pour obtenir une efficacité optimale, les recommandations dans ces trois secteurs doivent être mises en œuvre simultanément. Cette ligne directrice remplace le soin centré au client précédent .

    Association des infirmières et infirmiers autorisés de l’Ontario. (2015). Soins axés sur les besoins de la personne et de la famille. Toronto (Ontario) : Association des infirmières et infirmiers autorisés de l’Ontario http://rnao.ca/bpg/language/soins-ax%C3%A9s-sur-les-besoins-de-la-personne-et-de-la-famille

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    In this article the authors review how to assess falls risk and discuss some key factors for falls and potential interventions to mitigate risk. They provide two case scenarios that demonstrate why individual risks need to be carefully explored.

    Reference: Willy,Betty. PT, MA, CWS & Osterberg, Christine M. RN, BSN. Strategies for Reducing Falls in Long-Term Care. Annals of Long-Term Care: Clinical Care and Aging. 2014. Retrieved November 17, 2017 from https://www.managedhealthcareconnect.com/article/strategies-for-reducing-falls-long-term-care 

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    Care plans for Stroke survivors in Long Term Care provide tips, information and 12 Stroke specific care plans that long term care homes can use in integrating stroke care for their residents and into the documentation care plan libraries.

    Web Address or Source: http://ontariostrokenetwork.ca

    Reference: Ontario Stroke Network. Stroke Care Plans for Long-Term Care. Clinical Tools and Resources for Implementation: Community Re-engagement. Retrieved from http://ontariostrokenetwork.ca/stroke-qbp-resource-centre/stroke-rehabilitation-resource-centre/clinical-tools-and-resources-for-implementation/clinical-tools-resources-implementation-community-re-engagement/ 

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    This care plan was developed to support stroke best practices in Long Term Care Homes. It is one of a series of piloted stroke care plans based on the best practice resource Taking Action for Optimal Community & Long Term Care Stroke Care.

    Reference: Ontario Stroke Network (2016) ontariostrokenetwork.ca Retrieved from http://ontariostrokenetwork.ca/stroke-qbp-resource-centre/stroke-rehabilitation-resource-centre/clinical-tools-and-resources-for-implementation/clinical-tools-resources-implementation-community-re-engagement/ 

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    A summary of the recommendations of RNAOs Best Practice Guideline on Preventing Falls and Reducing Injury from Falls (3rd ed.).

    Registered Nurses’ Association of Ontario.  (2017).  RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author.

     

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    This is a resource manual for LTCHs on how to develop a successful person-centred Fall Prevention Program. It details and provides resources such as who should be members of the fall prevention team and their job descriptions, education modules for PSWs, registered staff and families, post fall risk assessments and documentation, environmental fall risk screening and a host of other QI tools.

    Reference: Taylor,J., Parmelee, P., Brown, H., & Ouslander,J. (2005). The Falls Management Program: A Quality Improvement Initiative for Nursing. Retrieved from https://www.ahrq.gov/sites/default/files/publications/files/fallspxmanual.pdf 

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    Timed Up and Go test (TUG) is a test of basic functional mobility for older adults. It is used by clinicians to screen for the risk of falling.

    Reference: Podsiadlo, D. and Richardson, S. (1991). "The timed "Up & Go": a test of basic functional mobility for frail elderly persons." J Am Geriatr Soc 39(2): 142-148. Retrieved from http://www.lhsc.on.ca/Health_Professionals/Joint_Replacement_Surgery/Treatment%20Guidelines/TimedUpandGoTest.pdf 

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    This tool is useful to assess balance and gait for older adults.

    The Hartford Institute for Geriatric Nursing. New York University College of Nursing. Retreived from ConsultGeriRN.org http://consultgerirn.org

    ConsultGeriRN.org is funded in part by a grant from The Atlantic Philanthropies (USA) Inc. and The John A. Hartford Foundation.

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    Example signage of Universal Falls Precautions Poster from Fraser Health, British Columbia, Canada.

    Registered Nurses’ Association of Ontario.  (2017).  Appendix K of RNAO Prevention of Falls and Reducing Injury from Falls Best Practice Guideline. (4th Ed.).  Toronto, ON: Author. (p.114.) 

    Reference: Registered Nurses’ Association of Ontario. (2017). Preventing Falls and Reducing Injury from Falls (3rd ed.). Toronto, ON

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    Webinar Presentation by Vision Nursing Home's Kathleen Waller, BPSO Lead and Charge Nurse An overview of Vision Nursing Home's journey through their BPSO year one candidacy while implementing the Best Practice Guideline on Prevention of Falls and Fall Injuries in the Older Adult. It highlights strategies and processes during implementation and for sustainability, includes challenges and successes, data collection, monitoring and evaluation.

    Kathleen Waller. [Registered Nurses' Association of Ontario]. (2016, Jan 28). Best Practice Spotlight Organization's journey in implementing the Prevention of Falls in the Elderly best practice guideline. [Video]. YouTube. https://youtu.be/gSqA_7fduWA