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VA Sunshine Healthcare Network


Patient Safety Center of Inquiry Projects & Products

Nurse assists older female patient


In 2015, we combined our Safe Patient Handling and Mobility Conference with our Falls Conference by adding a specialty track on Fall and Fall Injury Prevention. This conference is designed to meet the needs of direct care providers, managers, administrators, risk managers, educators, industrial hygienists/safety professionals, and researchers of any discipline who are interested in advancing safety for patients and caregivers with tracks on Safe Patient Handling and Mobility in Rehabilitation, Challenges for Special Populations & Settings in SPHM, and Implementation/Evaluation Research in SPHM.These conferences have been providing an opportunity for sharing our work and creating collaborative opportunities since 2001. The The falls track assembles faculty whose expertise is nationally known for shaping healthcare delivery systems and approaches to improving patient safety focusing on falls including lessons learned, best practices, and cutting-edge research findings related to safety for patients at risk for mobility-related adverse events. For information on our most current conference contact


For many years we have been providing a Technology Resource Guide to assist clinicians in the field to know what is available in the market. This is a guide only from a snapshot in time. New technologies are appearing all the time, so be sure to do a complete internet search as well for any equipment that you are looking for. We also have a Bariatric Toolkit with tips and tricks for patient handling and assessment. Here is a link to the products page where you will find these tools: click here


Fall Injury Prevention Focus Area

Project 1. Falls Patient Safety Assessment Tool (PSAT) Redesign. Plan: Revise the Falls PSAT to serve as a better cognitive aid for patient safety managers to more precisely assess facility falls injury prevention practices. We will develop a new Falls PSAT item pool, validate the redesigned Falls PSAT items using feedback from patient safety managers and experts, pilot test with volunteer facilities, analyze facility IPEC rate of falls with major injuries, and deliver the redesigned Falls PSAT to NCPS for national distribution.

Project 2: Analysis of Assisted and Witnessed Falls IPEC data. Plan: Establish benchmarks on prevalence of witnessed and assisted falls and injury outcomes for different care settings (acute care, long term care, behavioral health). We will initiate data collection on assisted falls in the VHA following the start of mandatory IPEC data reporting requirements. We will analyze IPEC data and compare fall/fall injury rates both during and after the COVID-19 pandemic, as the pandemic might have affected existing practices.

Project 3: Assisted Falls Virtual Reality (VR) Staff Training. Plan: Redesign the VR assisted fall scenario into an immersive VR simulation for staff training and evaluate its effectiveness to prepare staff to more appropriately respond to assisted falls. A collaborative team approach will be used to create the assisted falls staff training materials based on results from the current project and input from experts in ergonomics, physical medicine and rehabilitation, and simulation-based education.


The Home Based Primary Care (HBPC) Fall Risk Screening and Assessment Toolkit -- Click here to download

The goal of this fall risk screening and assessment toolkit is to educate Home Based Primary Care Interdisciplinary Team members on validated fall risk screening tools which can be used to identify community dwelling patients at risk for fall. This represents a shift from using tools that are validated for inpatients. Additionally, this action plan shares identified National HBPC Best Practices regarding falls, a HBPC Fall Assessment Flowchart, sample CPRS templates, plus educational materials for fall evaluation and injury prevention strategies.  

Evaluation of best practices in fall injury prevention in VHA Plan: Conduct a secondary analysis of the new Falls Patient Safety Assessment Tool (PSAT) and existing Patient Safety Culture survey to identify best practices, policies, and procedures for the prevention of falls and fall-related injuries. We will identify high/low performing facilities (using Inpatient Evaluation Center (IPEC) data), and examine associations with practices employed in each care setting (acute, behavioral health, and long-term care), patient safety culture domains, and falls and fall-related injury rates.

Assisted falls in VHA Plan: Develop guidance for when to rescue, and how to rescue a falling patient during a witnessed fall event. We will initiate data collection on assisted falls in VHA by adding fields in the mandatory IPEC data reporting requirements. We will interview VA staff with experiences with assisted falls to identify typical scenarios resulting in injury vs. no injury and develop most common fall scenarios that will be evaluated in a laboratory setting to determine circumstances when, and if, it is safe for staff to attempt to rescue the falling patient without risking injury.

Post Fall Virtual Simulation Training Plan: Develop a virtual simulation of post fall assessment training for nursing staff; evaluate the cognitive processing and clinical reasoning during the simulation experience; and measure the acceptability and usefulness of the virtual simulation training.

Evaluation of injury prevention practices related to sling and transfer device utilization Plan: Evaluate evidence on pressure ulcers (PU) and injury risk related to lift device slings and/or air transfer devices; describe current practices and availability of sling devices across the nation; describe patient PU and injury rates and evaluate association related to use or non-use of these devices; and develop tools/educational materials to facilitate best practices in the use of patient transfer equipment and prevention of PU.


Bulat, T., Kerrigan, M. V., Rowe, M., Kearns, W., Craighead, J. D., & Ramajah, P. (2016). Field evaluations of tracking/locating technologies for prevention of missing incidents. A J Alzheimer's Dis Other Demen, 31(6), 474-480.

Quigley, P. A., Barrett, S. D., Bulat, T., & Friedman, Y. (2016). Reducing falls and fall-related injuries in medical-surgical units: One-year multihospital falls collaborative. J Nurs Care Qual, 31(2), 139-145.

Barrett, B., Bulat, T., Schultz, S. & Luther, S. Factors associated with wandering behaviors in veterans with mild dementia: A prospective longitudinal community-based study.  American Journal of Alzheimer’s Disease & Other Dementias. DOI: 10.1177/1533317517735168