Fall prevention among children in the presence of caregivers in a paediatric ward: a best practice implementation


Correspondence: Ms Yee Ling Geraldine Lee, University Children's Medical Institute, National University Hospital, 5 Lower Kent Ridge Road, Main Building Level 4, 119074 Singapore. Email: lee.ylg@gmail.com



This study aims to reduce the incidence of falls in paediatric inpatients aged 3 and below by implementing fall prevention strategies.


The Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programmes were used for this project. The project was carried out in three phases over a 4-month period from March to June 2011. A fall prevention poster was introduced during the implementation phase, and pre- and post-implementation audits were carried out in a 43-bed acute care paediatric ward in Singapore, with a sample size of 30.


The audit result of Criterion 1, evaluating the effectiveness of the fall prevention measures, improved by 13%, to 93%. Criterion 2, measuring nurses' compliance in the regular reinforcement of safety, improved significantly by 27%, to 40%. However, Criterion 3, which measured nurses' compliance in identifying patients at high risk of falls by placing a green identification wrist tag on such patients, decreased by 23%, to 50%.


A multi-language poster on fall prevention was strategically positioned at the foot of all the cots. The poster served as an effective reminder and communication method between nurses and caregivers and also among caregivers of the child. Caregivers' increased awareness and knowledge of fall prevention contributed to a 50% decrease in fall incidence of patients aged 3 and below in the presence of a caregiver from January to June 2011, as compared with the incidence rate in 2010.


This project has shown that fall incidents can be reduced when caregivers' awareness of fall prevention measures in the hospital setting were to be improved. The poster on fall prevention has increased caregivers' awareness and reduced inpatient falls in the acute care setting. The pre- and post-implementation audits showed that the presence of a poster on fall prevention to remind parents/caregivers to raise and securely lock the cot rails at all times was effective in reducing the number of falls for children aged 3 years and below. The experience gained from this project was that communication to every staff member and caregivers is essential in implementing practice change. As a result of the study, the hospital plans to implement constant monitoring and reminders to nurses and caregivers to improve compliance to the recommended measures on fall prevention in the near future.


Falls are the most common cause of injuries from accidents in the paediatric population.[1] The majority of reported inpatient accidents that occurred in the hospital are contributed by falling from elevated surfaces.[2-4] Falling is most frequent among babies and toddlers, compared with children of other age groups.[5-7] Studies have shown that about 56% of falls from bed in hospitals and 47% at home occur to patients aged 3 years and below.[8, 9] The Joanna Briggs Institute (JBI) and a study done by Razmus revealed that children aged 3 years and below are more susceptible to unanticipated falls in the hospital because of their unsteady gait, present illness and unfamiliar environment.[10, 11] The study also states that the presence of caregivers in the room does not prevent falls of children in the hospital.[4, 7, 11] This is because caregivers tend to be distracted, less attentive and less vigilant in a new environment during their child's hospitalisation due to stress and anxiety.[5, 11] Inpatients falls are a nursing-sensitive quality indicator in many organisations, such as Joint Commission and Magnet Recognition Program.[2, 12]

In the paediatric wards of the National University Hospital (NUH) of Singapore, existing fall prevention measures include educating parents and caregivers on safety and fall prevention measures at the time of admission and reinforcing them regularly. A green wrist/ankle tag is placed on children who are identified as being at high risk of falls. Patients' fall risk status is communicated among the nursing staff during the handover of duties between shifts. The hospital also allows and encourages one caregiver to stay with the patient at all times during the child's hospitalisation. Incidents of falls in the hospital are recorded in patients' medical records and the electronic Hospital Occurrence Report (eHOR). It is the hospital's policy that all accidents occurring in the hospital are to be reported through the eHOR, including falls. The eHOR shows that the incidence of falls rose by 100% from 0.57 falls per 1000 patient days in 2009 to 1.10 falls per 1000 patient days in 2010. The hospital's eHOR database revealed that 60% of paediatric fall incidences, involving children aged 3 years and below, were in the presence of a parent or caregiver. This is despite the reinforcement of explanation on fall risks given to caregivers upon admission and throughout hospitalisation. A survey done by Banco and Powers revealed that cot sides being left down by parents or caregivers contributed to and are the cause of all crib-related falls.[3] Therefore, prevention of falls should be a priority for hospitals, and strategies targeted at caregivers would be useful.[1] Recommendations to reduce the incidence of falls in the paediatric inpatient setting include providing fall prevention-related education to patients' family and caregivers.[1] This project aims to reduce the incidence of falls in the paediatric inpatient setting by establishing useful risk-reduction strategies.


The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) programmes, both pre- and post-implementation audit strategies, were used for this project. These online programmes adopt a process of gap identification, development of action plan and re-audit as a means of improving standards of clinical practice.[13] This project consists of three phases over a 4-month period from March 2011 to June 2011.

Phase 1: preparation for audit

Phase 1 necessitated determining an audit topic, assembling the project team, setting up of JBI-PACES, identifying audit criteria, establishing the setting and sample size, and executing a pre-implementation audit.

Establishing the project team

The project was presented to the key stakeholders. The project team, led by a registered nurse, consists of two nurse educators and four other registered nurses. The team members were chosen because they were registered nurses working in the ward, as they have vested interest in seeing the project to success. The project was introduced to the team, in which the rationale on selection of the topic, audit criteria and duration of the project were highlighted. The team leader personally briefed and trained the members on the audit process. The team met fortnightly to update and resolve any obstacles encountered during the audits and implementation.

Setting up of JBI-PACES

The audit criteria were adapted from JBI-PACES. Permission to adapt the audit criteria was granted by JBI as our hospital is one of the collaborating centres of JBI. Team members developed the mode of assessment based on the selected audit criteria and determined the sample size. Pre- and post-implementation audits were done by the same group of team members. The audit data were entered into JBI-PACES.

Identifying audit criteria

Three out of eight JBI-PACES criteria were chosen as audit criteria for the project. These three criteria helped us to identify the possible gaps, in the education of fall prevention to caregivers, which we aimed to close by implementing this project.

Criterion 1

Fall risk preventive interventions were evaluated. The criterion was met when parents/caregivers were observed to adhere to fall preventive instructions being taught by the nurses. By means of a physical check, parents/caregivers should be found to have demonstrated compliance to the following measures:

  • 1Do not leave child unattended with cot rails down.
  • 2All cot rails are properly secured.
Criterion 2

Patient and family education (PFE) was carried out for parents/caregivers of children at risk of falls. This criterion was met if the caregiver is able to verbalise components of the education given to them.

Criterion 3

Patients at high risk of falls based on hospital's guidelines were identified. This criterion was met when the patient identified wore a green tag at the wrist or ankle and when a green label was placed at the headboard of patient's cot.

Identifying the setting and sample size

The project was piloted in a 43-bed paediatric multidisciplinary ward in a tertiary hospital in Singapore. Convenience sampling was done on 30 patients who were aged 3 and below and had been admitted for more than 24 h. The sample size was decided based on the requirement of the Joint Commission International, where a sample size of 30 is sufficient for a population of 30–100.[14]

Conducting the pre-implementation audit

A pre-implementation audit was conducted in March 2011 to collect information on the compliance of nurses in conducting education and on the effectiveness of the fall prevention measures. The audit data were collected over 3 weeks by interviewing caregivers, and then entered into the JBI-PACES programme. The audit results were analysed using the JBI-PACES programme and presented to the ward staff in a briefing session.

Phase 2: implementation of best practice

Using GRiP strategies to identify barriers

In this phase, the team utilised the JBI-GRiP strategies to identify barriers for effective fall prevention measures and develop strategies to improve fall prevention. An action plan was also formulated and implemented. Evaluation of strategies was done by a post-implementation audit.

The pre-implementation audit found that 87% or 26 out of 30 caregivers could not perform a return demonstration on the proper handling of cot rails, or verbalise the content of the education received on fall prevention. In addition, 6 out of 30 caregivers were found to have not adhered to fall prevention instructions. The caregivers whom we interviewed reported that the education was only carried out at the time of admission when they were expectedly too anxious and were more focused on their child's medical condition; they highlighted that in order for them to retain the knowledge, education needs to be re-enforced during the hospitalisation. Some also expressed that they were not the primary caregiver or were not present at the time of admission. The nurses' response to failing to re-enforce education during hospitalisation was that they lacked the time to do so because of heavy workload and high turnover of patients.

Identify strategies to improve practice

The team met up to discuss and brainstorm the following strategies to overcome the barriers identified above:

  • 1Perform reinforcement and PFE on fall prevention measures during physical checks conducted during handover of duties between shifts. The reinforcement education was simplified into three simple statements:
    • Please do not leave your child alone.
    • Please raise and securely lock both bed rails when not attending to your child.
    • The green wrist tag on your child's wrist or ankle indicates that he/she is at high risk of falls.
  • 2Design and develop a poster on fall prevention (Appendix S1), which consists of pictures on the correct methods of locking the cot rails, optimal height of cot rails to be raised and risk of child falling from the cot. This poster was placed at the foot of the cot to serve as a reminder and as an aid for conducting PFE on safety and fall prevention measures. The poster on fall prevention contained information in four languages according to the ethnic groups of the local population: English, Mandarin, Malay and Tamil. Using pictures as visual aids, the poster was especially beneficial to underprivileged caregivers who had had no formal education. The aim of the poster on fall prevention was to serve as a constant reminder to caregivers to handle or lock the cot rails properly at all time.

Agreeing to a time frame for implementation

The team agreed that the above strategies would be implemented over 8 weeks from April to May 2011.

Phase 3: post-implementation audit

A post-implementation audit was held 8 weeks after the implementation of the above strategies using the same audit tool as the pre-implementation audit. The results of the audit were analysed to assess the effectiveness of the implementation and then presented to the key stakeholders.

Data analysis

The findings of the pre- and post-implementation audits for the three criteria were analysed descriptively. A Fisher's exact test was used to measure the impact of the implementation, with the significance level set at 0.05.

Ethical considerations

Formal ethical approval was not required as this project was conducted in accordance with the hospital's clinical quality improvement policy.


Pre-implementation audit

The pre-implementation audit result is shown in Figure 1. The audit found that 24 (80%) of the caregivers were able to secure the cot rails properly (Criterion 1). Among the 30 caregivers we interviewed, only four caregivers (13.3%) recalled receiving reinforcement of fall prevention information on children at risk of falls (Criterion 2). Eight (26.7%) out of 30 patients who were at risk of falls were not wearing the green wrist/ankle tag or did not have a green label at their beds (Criterion 3). The poor compliance rate of Criterion 2 revealed that the nurses did not adhere to the best practice on fall prevention intervention.

Figure 1.

Results of pre- and post-implementation fall audit. Criteria legend: 1. Fall risk prevention interventions were evaluated (30 of 30 samples taken). 2. Patient and family education was carried out for patients at risk of falls (30 of 30 samples taken). 3. Patients at high risk for falls were identified (30 of 30 samples taken).

Post-implementation audit

The post-implementation audit presented an improvement in 2 out of 3 audit criteria, in addition to a decrease in fall rates.

The results of the post-implementation audit are shown in Figure 1. The compliance rate of Criterion 1 has improved by 13%, from 24 caregivers (80%) in the pre-implementation audit to 28 caregivers (93%) (P = 0.254, degree of freedom (d.f.) = 1, Fisher's exact test) (Table 1), but the change was not statistically significant. Criterion 2 has improved significantly to 40%. In post-implementation, 12 caregivers are able to recall receiving information on fall prevention as compared with four caregivers (13%) in the pre-implementation audit (P = 0.039, d.f. = 1, Fisher's exact test). The compliance rate of Criterion 3 dropped to 50% (15 out of 30 caregivers), a decrease of 23% (seven caregivers) from the pre-implementation audit (P = 0.110, d.f. = 1, Fisher's exact test).

Table 1. The number of samples for each criteria and the degree of compliance
CriteriaBaseline auditPost-implementation auditP-value (Fisher's exact test)
Sample sizeCriteria met (%)Sample sizeCriteria met (%)
Fall risk preventative interventions are evaluated3024 (80)3028 (93)0.254
Patient and family education is carried out for patients at risk of falls304 (13)3012 (40)0.039
High risk of falls is identified3022 (73)3015 (50)0.110


Fall prevention has always been of great importance to the inpatient paediatric unit of our hospital; therefore fall rate serves as one of the key performance indicators. This is because very young children are prone to falls, and falls are the most common causal factor of head injury among children, compared with other age groups.[15] The implementation of the fall prevention poster, which complimented the existing fall prevention measures, successfully reduced the overall fall rates in the piloted ward from 1.0 falls per 1000 patient days in April–June 2010 to 0.3 falls per 1000 patient days in April–June 2011. A deeper analysis of the eHOR records revealed that there is a 100% reduction of falls incidences occurring to children aged 3 years and below and in the presence of caregivers from April–June 2010 to that in 2011.

Utilising the JBI-PACES tool, which was easily accessed from the website of JBI, we were able to evaluate the effectiveness of the fall preventive interventions. Comparing the pre- and post-implementation audits, the results of Criterion 1 improved from a compliance rate of 80% to 93%. The poster on fall prevention (Appendix S1) was designed to include pictures depicting a child dangerously leaning over cot rails that were down or improperly secured and served to alert caregivers that such situations could occur to their own child in the ward. The poster on fall prevention also contained pictures instructing the optimal height of cot rails to be raised. This meant that with the implementation of the poster on fall prevention, caregivers would be more aware that the child was exposed to the risk of falling and they would be more aware of the proper security of the cot rails. The increase in awareness and knowledge of fall prevention among the caregivers has led to a change in behaviour. The number of caregivers leaving the child unattended with the cot rails down or improperly secured was reduced during the post-implementation audit as spotted by the auditors. This change in behaviour has also resulted in a 50% decrease in fall incidents from January to June 2010 among patients aged 3 and below in the presence of a caregiver. The result of this project support findings by Rivara and Sacks (1994) that increasing awareness of injury-control efforts enhances the effectiveness of education in fall prevention.[16]

The results of Criterion 2 show an increase in the compliance rate from 13% in the pre-implementation period to 40% in the post-implementation period. Criterion 2 shows the compliance of nurses in the regular reinforcement of safety measures, which is measured by caregivers' ability to understand and retain taught information. The reinforcement of safety measures using the three simplified statements with the aid of the poster on fall prevention served to enhance caregivers' understanding. The poster on fall prevention was secured to the inner aspect of the foot of the cot in order to capture the attention of caregivers at all time, because from observation, caregivers usually sit on a chair beside the bed or lie in bed while comforting the child. Taking into consideration that Singapore is a multiracial country, the team decided to include the four main languages of the country – English, Mandarin, Malay and Tamil – in the statements used in the posters. In addition, the poster contained more pictures than words, which were easily understood by caregivers who could not read. The careful positioning of the posters and inclusion of different languages on the poster was an effective communication method in preventing falls among the paediatric patients in the ward.[7, 17, 18]

Caregivers have also given unsolicited feedback to auditors that they found the poster very useful as it served as a constant reminder to them of the child's safety. A small number of caregivers also voiced that they had missed out on the safety education given by the nurses upon admission as they were not the primary caregivers. However, they could now rely on the poster for important instructions on fall prevention. The poster not only aided in the communication of fall prevention from nurses to caregivers but also that between the different caregivers of the same patient.

The result of Criterion 3, the use of a green wrist tag and a green label placed on the headboard of the bed for patients identified at high risk of falls, was decreased from 73% to 50%. The green wrist tag was not attached on 15 patients at high risk of falls during the post-implementation audit. This could be because during the post-implementation audit period, a new type of wrist tags, adhesive tags instead of button tags, had just been implemented hospital wide. The nurse manager received feedback from nurses that the new wrist tag could be easily removed from the limb and was too big for small children. Caregivers were encouraged to remind the staff to replace the wrist tag whenever it came off and constant monitoring by team members to ensure that all patients are properly tagged may be helpful in the future.

It will be challenging to improve and sustain the compliance rates. Nurses in the ward were briefed and educated about the new intervention through presentation sessions during the implementation phase. However, not all nurses attended the presentation sessions as some of them were absent because of vacation. Although these nurses could obtain the information from the message book used to relate information to all the nurses in the ward, it may not be as effective in relating information as the presentation sessions due to the lack of interaction.

The 100% reduction of fall incidences occurring to children aged 3 years and below and in the presence of caregivers from April to June 2010 to that in 2011 is very encouraging. However, this could be a transient improvement, as the result was monitored within 3 months from the implementation of project. Therefore, in order to achieve long-term sustainability, regular audits should be in place to monitor and to serve as a constant reminder to nurses and caregivers. Plans are also in place to extend the implementation to the other inpatient paediatric wards of the hospital.


This project has shown that fall incidence can be reduced when awareness of fall prevention in the hospital setting among caregivers was improved. As stated in the JBI evidence summary, merely having a caregiver nearby the child at all times does not prevent falls in hospitals. Family and caregiver education highlighting effective fall prevention interventions increases caregivers' awareness and thus reduces falls in the acute care setting. The mere presence of a poster on fall prevention to remind parents/caregivers to raise and securely lock the cot rails at all times was effective in reducing the number of falls for children aged 3 years and below, as revealed by the results of our study.

The implementation of practice change in the clinical setting was challenging, primarily due to the high patient turnover rate, heavy workload and oversight by ward staff. The experience gained from this project was that communication to every staff member and caregiver is essential for an effective outcome.


The authors are deeply grateful to the deputy director of clinical and oncology nursing, Dr Neo Kim Emily Ang; the deputy director of nursing administration, Dr Siow Lan Catherine Koh; senior nurse managers, Kim Ngah Tay and Luen Ying Lim; nurse educator, Mary Mui Leng Tan; nurse managers, Sivagamu D/O Kunjoo and Choy Foon Felicia Soh; and nurse clinician, Elaine Hor, for their support and advice in making this project a success.

We would like to thank all the staff of the paediatric ward in NUH for participating in this project, and team members, RN Nur'Asyikin Binte Rahim, RN Regina Ying Jie Yap and RN Desmond Yong Yuan Lee for their efforts and contribution. We would also like to thank the Publications Support Unit of National University Health System for reviewing this manuscript.