Please complete work on the capstone project, including the poster. 


Falls in a Psychiatric Unit


Institutional Affiliation


Falls in a Psychiatric Unit

           The psychiatric unit in St. Mary & Elizabeth Medical Center has been experiencing the problem of patient falls associated with medications, such as benzodiazepines, barbiturates, Prozac, and Ativan, which have a drowsiness and dizziness effect. The frequent patient falls that have occurred over the last three months have caught the attention of the head nurse in the psychiatric unit. Falls have become a safety concern as it exposes patients in the behavioral health unit to injuries that lead to additional care needs, prolonged hospital stays, and increased cost of care. Since the use of these psychiatric medications may be inevitable in mental health care, fall prevention has been documented as the priority issue that needs an urgent and effective solution. There is a need to identify an intervention to address the patient safety issue by addressing the risk factors. 

           The head nurse in the psychiatric unit stated that there had been challenges in monitoring patients after they had received the medications due to a large number of patients in the unit. Additionally, the nurse manager has emphasized the need to address the issue and reiterated that it is a priority patient concern. The head nurse has been given the role to explore the cause of the issue and find ways to mitigate the problem.

           The prevention of patient falls after taking the medications would improve the safety and welfare of the patients, which is one of the current objectives of the psychiatric unit. The achievement will also benefit the organization as improvement of patient safety is also a priority for the facility. Fall prevention would improve treatment outcomes and help avoid the complications associated with falls, such as prolonged duration of patient stays; thus, the unit will benefit from a reduced burden of care. 

Literature Review of the Problem

           Research on patient falls in psychiatric facilities have associated psychotropic medications with increased fall risk. 

           Du et al. (2017) investigated the relationship that exists between the psychotropic medication use and falls in older adults. The researchers established that participants who had higher psychotropic medication use experienced falls. The patients that were more likely to fall had used antidepressants. The authors reported that recurrent falls were common among individuals who used psychotropic drugs. The researchers concluded that the psychotropic medication use contributed to higher fall risk in older adults. The article is important for the current project as it provides evidence that associates psychotropic medications with falls, which can be essential in identifying individuals at a higher risk when im






















Downloadedfrom July l Nursing2012 l 65


FALL PREVENTION is an ongoing
challenge in older patients in the
inpatient acute mental health setting
(IAMHS). Fall prevention and patient
safety committees should work
together to minimize the risk.

This article discusses why falls
occur and how to prevent them in
older adults with mental health prob-
lems in an inpatient setting. Incorpo-
rating fall prevention toolkits and
evidence-based practices is vital.

Sizing up the problem
Each year, one in every three adults
age 65 and older falls.1 Preventing or
reducing the number of falls is a
challenge in most healthcare settings,
but the challenge is even greater in
the IAMHS. In the psychiatric or
behavioral health setting, fall rates
range from 4.5 to 25 falls per 1,000
patient days.2

In the IAMHS, many factors con-
tribute to patient falls. These factors
can be intrinsic, extrinsic, situational,
or a combination.3

• Intrinsic factors associated with an
increase in falls in an IAMHS include
impaired cognition resulting from a
chronic condition such as Alzheimer
disease or an acute condition such as
delirium. In addition, psychotropic
medications and their adverse reac-
tions may increase the likelihood of
patient falls. Other intrinsic factors
that may lead to falls include mobility,
gait, vision, and balance disorders.
• Extrinsic factors (environmental
factors) that may contribute to patient
falls on the IAMHS include a lack of
support equipment, such as side rails
when patients are getting into and out

of bed, or a lack of durable medical
equipment (DME), such as walkers,
canes, and lifting devices. To add to
these problems, mental health units
have environmental restrictions to
protect patients from harm.4 For
example, wired chair and bed alarms,
side rails, and call systems with cords
can endanger patients and staff. These
issues can account for the lack of sup-
port equipment or DME.
• Situational factors (factors related
to activities) occur when patients are
attempting to perform more than one
task at a time, such as getting out of a
wheelchair while conversing.

Intervening to improve safety
Patient safety programs apply human
factors engineering concepts and a
systems approach to fall prevention.
To help prevent repeat fa

Capstone Project: Prevention of Falls in Psychiatric Patient Population

Michael Wolf


Applications in Evidence-Based Practice for BSN I

NUR 4775

Dr. Susan Schultz, DNP, RN


Leadership & Management


Professor Charlyn V. Myatt

November 14, 2015


Capstone Project: Prevention of Falls in Psychiatric Patient Population

Capstone Part I: Integrated Literature Review

Introduction to Problem

The purpose of this paper is to search the literature to see if the use of simple orthostatic blood pressure monitoring can assist in reducing the number of falls on an in-patient psychiatric unit along with patient and staff education on prevention of falls. “The financial burden associated with patient falls is approximately $20.2 billion each year, and as many as 25 percent of elderly patients who fall will die from the fall or from related complications” (Davis, 2012, p. 1). In- patient falls have become a financial burden to hospitals because the Centers fo

Psychotropic Medications and Risk for Falls Among
Community-Dwelling Frail Older People:

An Observational Study

Francesco Landi,

Graziano Onder,

Matteo Cesari,

Christian Barillaro,

Andrea Russo,

and Roberto Bernabei,

on Behalf of the

Silver Network Home Care Study Group

Department of Gerontology-Geriatrics, Catholic University of Sacred Heart, Rome, Italy.

Sticht Center on Aging, Wake Forest University-Baptist Medical Center,

Winston Salem, North Carolina.

Background. Injuries due to falls are one of the most important public health concerns for all ages, but especially for
frail elderly people. Although a small number of falls have a single cause, the majority have many different causes
resulting from the interactions between intrinsic or extrinsic risk factors.

Methods. We conducted an observational study on data from a large population of community-dwelling elderly people
to tests the hypothesis that the current use of different classes of psychotropic medications, including antipsychotic agents,
benzodiazepines, nonbenzodiazepine sedative-hypnotics, and antidepressants, increases the risk for falls. We analyzed
data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected
data on patients admitted to home care programs (n ¼ 2854).

Results. After adjusting for all potential confounders, users of any psychotropic drugs had an increased risk of fall of
nearly 47% (adjusted odds ratio [OR], 1.47; 95% confidence interval [CI], 1.24–1.74). Similarly, compared with nonusers,
users of atypical antipsychotic drugs also had an increased risk of falling at least once (OR, 1.45; 95% CI, 1.00–2.11).
Among benzodiazepine users, patients taking agents with long elimination half-life (OR, 1.45; 95% CI, 1.00–2.19) and
patients taking benzodiazepines with short elimination half-life (OR, 1.32; 95% CI, 1.02–1.72) had an increased risk
of falls. Patients taking antidepressants did not show a higher risk of falling compared to nonusers (OR, 0.92; 95% CI,

Conclusions. Our data suggest that, among psychotropic medications, antipsychotic agents and benzodiazepines are
associated with an increased risk of falls. Our findings do not support the hypothesis that preferential prescribing of short-
acting benzodiazepines instead of long-acting agents or atypical antipsychotic medications instead of typical agents will
substantially decrease fall risk associated with the use of these classes of drugs.

FALLS and their related injuries represent one of themajor health service problems among the elderly
population. Falls are responsible for considerable immobil-
ity, morbidity, and mortality among elderly people (1,2). In
the United States and other Western countries, it has been
estimated that 35%–40% of commun

Psychotropic drugs and the risk of fall injuries,
hospitalisations and mortality among older adults

Kristina Johnell1, Gudrun Jonasdottir Bergman2, Johan Fastbom1,2, Bengt Danielsson2, Natalia Borg2 and
Peter Salmi2

1Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and
Stockholm University, Stockholm, Sweden
2The Swedish National Board of Health and Welfare (Socialstyrelsen), Stockholm, Sweden
Correspondence to: K. Johnell, PhD, Professor, E-mail:
[email protected]

Objective: To investigate whether psychotropics are associated with an increased risk of fall injuries,
hospitalizations, and mortality in a large general population of older adults.

Methods: We performed a nationwide matched (age, sex, and case event day) case–control study
between 1 January and 31 December 2011 based on several Swedish registers (n=1,288,875 persons
aged ≥65years). We used multivariate conditional logistic regression adjusted for education, number
of inpatient days, Charlson co-morbidity index, dementia and number of other drugs.

Results: Antidepressants were the psychotropic most strongly related to fall injuries (ORadjusted: 1.42;
95% CI: 1.38–1.45) and antipsychotics to hospitalizations (ORadjusted: 1.22; 95% CI: 1.19–1.24) and
death (ORadjusted: 2.10; 95% CI: 2.02–2.17). Number of psychotropics was associated with increased
the risk of fall injuries, (4 psychotropics vs 0: ORadjusted: 1.53; 95% CI: 1.39–1.68), hospitalization
(4 psychotropics vs 0: ORadjusted: 1.27; 95% CI: 1.22–1.33) and death (4 psychotropics vs 0: ORadjusted:
2.50; 95% CI: 2.33–2.69) in a dose–response manner. Among persons with dementia (n=58,984),
a dose–response relationship was found between number of psychotropics and mortality risk (4 psycho-
tropics vs 0: ORadjusted: 1.99; 95% CI: 1.76–2.25).

Conclusions: Our findings support a cautious prescribing of multiple psychotropic drugs to older pa-
tients. # 2016 The Authors. International Journal of Geriatric Psychiatry Published by John Wiley &
Sons, Ltd.

Key words: aged; dementia; psychotropic drugs; Sweden
History: Received 11 August 2015; Revised 01 March 2016; Accepted 15 March 2016; Published online 25 April 2016 in Wiley
Online Library (
DOI: 10.1002/gps.4483


Mental disorders are a concern in old age (Volkert
et al., 2013). Pharmacological treatment with
psychotropic drugs (i.e. antipsychotics, anxiolytics,
hypnotics, and antidepressants) is usually standard
treatment and provision of psychotherapy is scarce
in this age group (Alvidrez and Arean 2002). In
addition to treatment of mental health problems, such
as depression, anxiety, and insomnia, psychotopic
drugs are also prescrib


Psychotropic Drug-Related Fall Incidents in Nursing Home
Residents Living in the Eastern Part of The Netherlands

Sarah I. M. Janus1 • Gezinus H. Reinders1 • Jeannette G. van Manen1 •

Sytse U. Zuidema2 • Maarten J. IJzerman1

Published online: 8 April 2017

� The Author(s) 2017. This article is an open access publication


Background Older people are more susceptible to falls

than younger people. Therefore, as the Dutch population

ages, the total number of falls and costs associated with

them will rise. The use of psychotropic drugs is associated

with an increased risk of falling. To create tailored fall-

prevention programmes, information on the magnitude of

the association between fall incidents and specific psy-

chotropic drugs or drug classes is needed.

Objective The goal of this study was to delineate the

associations between fall incidents and specific psy-

chotropic drugs or drug classes.

Methods In this retrospective cohort study, electronic

patient records, medication records and fall incident reports

were collected for 1415 residents receiving somatic or

psychogeriatric care in 22 nursing homes in the eastern part

of the Netherlands from May 2012 until March 2015.

Using a Cox proportional hazards model, we analysed the

magnitude of the association between psychotropic drugs

and the risk of falling for users and non-users of the psy-

chotropic drugs or drug classes.

Results Antipsychotics (adjusted hazard ratio [aHR] 1.49;

95% confidence interval [CI] 1.12–2.00) and hypnotics and

sedatives (aHR 1.51; 95% CI 1.13–2.02) increase the risk

of falling. There was no difference between the risk

incurred by typical and atypical antipsychotics. However,

within these groups, there were differences between the

most commonly prescribed drugs: haloperidol and queti-

apine were seen to have an association with falls, whereas

pipamperone and risperidone were not.

Conclusions The results suggest falls may be associated

with individual drugs rather than drug classes. Within the

drug classes, clear differences are evident between indi-

vidual drugs. Future fall-prevention programmes should

highlight the differential risks involved with the use of

specific psychotropic drugs, and doctors should take the

fall risk into account when choosing specific drugs.

Key Points

Falls within the nursing home population may be

associated with individual drugs rather than drug


Differences exist between individual drugs within

drug classes.

1 Introduction

Over 40% of nursing home residents experienc

This Provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted
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Preventing falls among older people with mental health problems: a systematic

BMC Nursing 2014, 13:4 doi:10.1186/1472-6955-13-4

Frances Bunn ([email protected])
Angela Dickinson (a.m.d[email protected])
Charles Simpson ([email protected])

Venkat Narayanan ([email protected])
Deborah Humphrey ([email protected])

Caroline Griffiths (caroline.griffith[email protected])
Wendy Martin ([email protected])

Christina Victor ([email protected])

ISSN 1472-6955

Article type Research article

Submission date 13 June 2013

Acceptance date 10 February 2014

Publication date 19 February 2014

Article URL

Like all articles in BMC journals, this peer-reviewed article can be downloaded, printed and
distributed freely for any purposes (see copyright notice below).

Articles in BMC journals are listed in PubMed and archived at PubMed Central.

For information about publishing your research in BMC journals or any BioMed Central journal, go to

BMC Nursing

© 2014 Bunn et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which

permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

mailto:[email protected]

Seeherunwong et al.
International Journal of Mental Health Systems (2022) 16:3


Staffing and patient-related factors affecting
inpatient falls in a psychiatric hospital: a 5-year
retrospective matched case–control study
Acharaporn Seeherunwong1* , Chanya Thunyadee1, Wipa Vanishakije2 and Pavinee Thanabodee‑tummajaree2

Background: The frequency and severity of falls of psychiatric inpatients in Thailand have not been previously
reported. Also, the risk factors of falls have been numerous and complicated. This study aimed to investigate the staff‑
ing factors and patient‑related factors that increase the likelihood of falls among psychiatric inpatients.

Methods: A five‑year retrospective matched case–control study was conducted that selected cases of inpatients
who fell and which were reported to the hospital risk management system. Subjects were compared to two control
patients from the same hospital (1:2) by age (± 5 years), sex, and admission the same year. The total sample consisted
of 240 patients. Univariate and multivariate conditional logistic regression was used to analyze the data.

Results: Of the eighty falls, 86.3% resulted in temporary harm and required intervention. The multivariate model
showed that three patient‑related factors were associated with increased inpatient falls: (1) having an acute psychotic
condition (adjusted odds ratio (AOR) = 4.34; 95% CI 1.45, 13.05; p < 0.05), (2) polypharmacy with more than four types
of medicines (AOR = 3.06; 95% CI 1.59, 5.88; p < 0.05), and (3) taking atypical psychiatric drugs (AOR = 2.74; 95% CI 1.35,
5.58; p < 0.05). Staffing for 26–50 patients in the wards was more protective for falls than with 25 or fewer patients
(AOR = .17; 95% CI 0.04, 0.72; p < 0.05).
Conclusions: The risk factors found may help assess fall risk and manage the number of patients in psychiatric units.
Drug dosage and drug interaction of antipsychotic drugs and cardiovascular agents with other medications and
drug administration timing before falls are recommended for further investigation. Also, staff ratio per patient and the
proportion of staff mix in psychiatric units need further study to establish adequate levels of surveillance to prevent
inpatient falls.

Keywords: Accidental falls, Case–control studies, Psychiatric hospitals, Risk factors, Staffing

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the arti


Association of psychotropic drug use with

falls among older adults in Germany.

Results of the German Health Interview and

Examination Survey for Adults 2008-2011


Yong Du*, Ingrid-Katharina Wolf, Hildtraud Knopf

Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin Germany

* [email protected]



To investigate the association of psychotropic drug use with falls among older adults in Ger-

many based on data from the National Health Interview and Examination Survey for Adults

2008–2011 (DEGS1).


DEGS1 collected data on drug use in the past 7 days and on falls occurred in the last 12

months. Study participants were older adults aged 65–79 years with complete data on drug

use and falls (N = 1,833). Odds ratio (OR) and 95% confidence intervals (95% CI) were

derived from logistic regression models adjusting for potential confounders including socio-

demographic characteristics, health-related behaviors (alcohol drinking), body mass index

and health conditions (frailty, vision impairment, disability, polypharmacy, blood pressure)

as well as use of potential falls-risk-increasing drugs. SPSS complex sample methods were

used for statistical analysis.


Compared to people without falls, people with falls (n = 370) had a higher psychotropic drug

use (33.1% vs. 20.7%, p < .001). After adjusting for potential confounders, use of psychotro-
pic drugs overall was associated with a higher risk of falls (OR 1.64, 95% CI 1.14–2.37).

This was particularly true for the use of synthetic psychotropic drugs (1.57, 1.08–2.28), anti-

depressants overall (2.88, 1.63–5.09) or synthetic antidepressants (2.66, 1.50–4.73), spe-

cifically, selective serotonin reuptake inhibitors (SSRIs) (6.22, 2.28–17.0). Similar results

were found for recurrent falls.

PLOS ONE | August 8, 2017 1 / 15







Citation: Du Y, Wolf I-K, Knopf H (2017)

Association of psychotropic drug use with

falls among older adults in Germany. Results of the

German Health Interview and Examination Survey

for Adults 2008-2011 (DEGS1). PLoS ONE 12(8):



Editor: Alessandra Marengoni, University of

Brescia, ITALY

Received: February 27, 2017

Accepted: July 18, 2017

Published: August 8, 2017

Copyright: © 2017 Du et al. This is an open access
article di

LWW/JNCQ JNCQ-D-13-00022 November 7, 2013 21:58

J Nurs Care Qual
Vol. 29, No. 1, pp. 51–59
Copyright c© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Reducing Falls and
Fall-Related Injuries
in Mental Health
A 1-Year Multihospital Falls

Patricia A. Quigley, PhD, ARNP, CRRN, FAAN, FAANP;
Scott D. Barnett, PhD; Tatjana Bulat, MD;
Yvonne Friedman, MS, OTR

Despite much research on falls occurring on medical-surgical units and in long-term care settings,
falls on inpatient psychiatry units are understudied. On the basis of fall injury program character-
istics across multiple inpatient psychiatry units, we developed and implemented an operational
strategic plan to address each falls prevention program element and enhance program infrastruc-
ture and capacity. Expert faculty provided lectures, coaching, and mentoring through biweekly
conference calls and collaborative e-mail exchange. Findings support continued efforts to integrate
measures to reduce serious fall-related injuries. Key words: fall prevention, fall-related injuries,
falls, injury prevention, psychiatry, veterans

A CONSIDERABLE body of research onfalls and falls prevention in hospitals
demonstrates that falling is a complex event

Author Affiliations: VISN 8 Patient Safety Center of
Inquiry (Drs Quigley and Bulat and Ms Friedman)
and HSR&D/RR&D Research Center of Excellence
(Dr Barnett), James A. Haley Veterans’ Hospital,
Tampa, Florida.

This material is based upon work supported by the
Office of Research and Development, Department of
Veterans Affairs, Health Services Research and Devel-
opment Service award #IIR-03-003-1, and the Patient
Safety Center of Inquiry, James A. Haley Veterans Af-
fairs Medical Center. The views expressed in this article
are those of the authors and do not necessarily repre-
sent the views of the Veterans Healthcare Administra-
tion or Department of Veterans Affairs.

The authors declare no conflict of interest.

Correspondence: Patricia A. Quigley, PhD, ARNP,
CRRN, FAAN, FAANP, VISN 8 Patient Safety Center of In-
quiry, James A. Haley VA Medical Center, 8900 Grand
Oaks Circle, Tampa, FL 33637 (patricia.quigley@va

Accepted for publication: July 8, 2013.

Published online before print: October 21, 2013

DOI: 10.1097/01.NCQ.0000437033.67042.63

that typically involves multiple risk factors.1,2

These risk factors involve person-specific in-
trinsic risk factors, the physical environment,
and the riskiness of a person’s own behav-
ior. Patient falls are the most frequent adverse
event associated with subsequent injury
within the Veterans Health Administration
(VHA)3 and are the leading cause of injury-
related deaths among people aged 65 years
and older.4 The 2 most serious fall-related
injuries are hip fractures and intracranial

Although falls on m


Preventing Falls Among Behavioral
Health Patients

An evidence-based fall prevention program yields positive results.

Inpatient falls are among the most common incidents reported in the acute care hospital setting. A 2015 review of 23 studies examin-
ing factors that contributed to falls among patients
in acute care hospitals found that the incidence of
fall-related injuries ranged from 6.8% to 72.1%.1
Recent research that examined changes in fall and
fall-related injury rates among hospital patients
showed a decrease in overall falls from 36% in
2001 to 19.5% in 2017 and, in the same period,
a more than 50% decrease (6% to 2.4%) in falls
that resulted in moderate or severe injury.2 The
researchers found a similar trend in the psychiat-
ric service line, with fall-related injuries decreas-
ing from 40% to less than 20% in the same time
period.2 Fall-related injuries are consistently among
the top 10 sentinel events reported by the Joint

Fall-related injuries have significant implications
for patients, staff, and organizations. Hospital

patients who have experienced a fall-related injury
can suffer from increased length of stay, reduced
independence (which may be temporary or perma-
nent), and a possible diminishment in overall qual-
ity of life.4 On average, length of stay increases by
six to 12 days at an additional direct cost of
$13,316; additional indirect costs to patients may
result from loss of income, skilled nursing facility
care, and litigation expenses.4-6 Further, there is a
significant inverse relation between nurse job satis-
faction and patient falls in the acute care setting.7

In the behavioral health setting, fall and fall-
related injury rates are higher than those on medi-
cal–surgical units.8, 9 The age of the patients in our
behavioral health acute care setting ranges from
18 to 90 years; patient mobility varies greatly;
and a variety of mental health disorders, includ-
ing substance use and abuse disorders, result in a
range of patient fall prevention and safety needs
and pose a challenge to traditional fall prevention

Background: Inpatient falls are among the most common hospital incidents reported. Fall-related injuries
have significant implications for patients, staff, and organizations. Adult behavioral health inpatients a