Pediatric Patient Fall and Injury Prevention Model

O R I G I N A L A R T I C L E
An interdisciplinary momentary confluence of events model to
explain, minimize, and prevent pediatric patient falls and
fall-related injuries
Nancy A. Ryan-Wenger and Janet S. Dufek
Nancy A. Ryan-Wenger, PhD, RN, CPNP, FAAN, is Director of Nursing Research, Nationwide Children’s Hospital, Columbus, Ohio; and Janet S. Dufek, PhD, is
an Associate Professor, Department of Kinesiology and Nutrition Sciences, University of Nevada Las Vegas, Las Vegas, Nevada, USA
Search terms
Falls, hospital, interdisciplinary, patient,
pediatric, theoretical model.
Author contact
nancy.ryan-wenger@nationwidechildrens.org,
with a copy to the Editor:
roxie.foster@ucdenver.edu
Disclosure: The authors report no actual or
potential conflicts of interest.
First Received November 30, 2011; Revision
received August 22, 2012; Accepted for
publication August 31, 2012.
doi: 10.1111/jspn.12009
Abstract
Purpose. This article reviews theoretical, empirical, and clinical evidence
to support the hypothesis that pediatric patient fall episodes are rarely pre-
dictable; rather, falls and fall-related injuries occur during the momentary
convergence of child, parent, and caregiver human factors, and environ-
mental, biomechanical, and system factors.
Conclusions. We propose an interdisciplinary pediatric fall and injury pre-
vention model to guide future research toward interventions to prevent or
minimize pediatric patient falls and injuries.
Practice Implications. When falls and near miss falls occur, nurses’
detailed descriptions of each model component are critical to discovery of
more effective pediatric fall and injury prevention methods.
Hospitalized patient falls, defined as any unplanned
descent to the floor (or onto an object) with or
without injury, are medical errors that have cap-
tured the attention of healthcare quality, and regula-
tory and third-party payers (Centers for Medicare
and Medicaid Services, 2011; Joint Commission,
2009; National Quality Forum, 2004). Current pedi-
atric fall prevention programs typically begin with
an evaluation of children’s risk for falls based on
scores from fall risk assessment tools. Children rated
as high risk receive special educational and environ-
mental fall prevention interventions (Child Health
Corporation of America [CHCA], 2009). Over a
6-month period, 26 children’s hospitals of varying
sizes reported that a total of 770 pediatric patients
fell to the floor from their cribs, beds, chairs, or
during ambulation (CHCA, 2009). Published
research shows that 6–60% of children rated as low
risk for falling actually fell during their hospital stay
(Harvey, Kramlich, Chapman, Parker, & Blades,
2010; Hill-Rodriguez et al., 2009; Razmus & Davis,
2012; Razmus, Wilson, Smith, & Newman, 2006;
Ryan-Wenger, Kimchi-Woods, Erbaugh, LaFollette,
& Lathrop, 2012; Schaffer et al., 2011). Many limita-
tions of pediatric fall risk scales, including false nega-
tive prediction rates of 47.3–55.7% and specificity
rates of 24–76%, are summarized in a recent article
(Ryan-Wenger et al., 2012).
In order to move beyond research that simply
compares fall risk status with whether or not chil-
dren fall, we conducted a content analysis of over
400 fall episodes from adverse event reports and
medical records of children who fell in our hospital
over an 8-year period. Similarities among the imme-
diate circumstances that preceded each fall led to the
conclusion that most fall episodes could not have
been predicted, at least not in time to prevent them
from happening. Rather, we hypothesize that falls
and fall-related injuries occur when certain human,
environmental, biomechanical, and system factors
converge during a brief moment in time. In rare
instances, only quick reflexes on the part of the
child, parent, caregiver, or others can prevent a fall.
Standard fall prevention interventions do not
address the momentary nature of patient falls
(CHCA, 2009).
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Journal for Specialists in Pediatric Nursing
4 Journal for Specialists in Pediatric Nursing 18 (2013) 4–12
© 2013, Wiley Periodicals, Inc.

We propose an interdisciplinary model supported
by our systematic analysis of research findings from
12 published articles on pediatric patient falls, as
well as theories and empirical evidence from nursing
and many other disciplines. We believe that a
research agenda based on this model could provide
new insights on fall prevention, and prevention or
minimization of fall-related injuries.
PEDIATRIC PATIENT FALLS AND FALL-RELATED
INJURIES
Pediatric patient falls are variously categorized as
physical, physiologically anticipated, physiologically
unanticipated, response to treatment, developmen-
tal, horseplay, or accidental (Graf, 2011; Kingston,
Bryant, & Speer, 2010; Razmus et al., 2006). We see
little value in categorizing falls at all, as it perpetu-
ates the notion that falls have only one causative
factor.
Fall-related injury rates were reported as 36%,
43%, and 58% in three studies (Graf, 2011; King-
ston et al., 2010; Levene & Bonfield, 1991). Most
injuries in pediatric settings occur on the head or
face (58–72%) from an impact with the floor or
other objects (Graf, 2008; Levene & Bonfield, 1991;
Schaffer et al., 2011). Head injuries have the greatest
potential to cause temporary or permanent harm
(Plunkett, 2001; Thompson, Bertocci, & Pierce,
2009). Current research on pediatric patient falls is
limited to assessment of risk for falling and strategies
to prevent falls. Very few authors include data on the
object that children fell from, injury rates, or the
location of injuries. There is no evidence of research
that addresses the severity, prediction, prevention,
or minimization of pediatric fall-related injuries or
postdischarge follow-up when patients do fall.
According to Graf (2011), injury severity “. . . may
be the most valuable measure of the quality of the
fall prevention program . . .” (p. 127). The severity of
injuries was reported in only two studies. Of 338
injuries, 91% were described as minor, 7% moder-
ate, and 2% severe (Levene & Bonfield, 1991). The
Pediatric Falls Benchmarking Collaborative from
three children’s hospitals reported that 99 of 272
(36%) falls in 1 year resulted in injury; 98% of the
injuries were minor, and 2% were moderate accord-
ing to criteria developed by the group (Kingston
et al., 2010). Many hospitals classify adverse events,
including patient falls, according to the level of
medical error that occurred and the level of patient
harm based on algorithms from the National Coordi-
nating Council for Medication Error Reporting and
Prevention (NCC-MERP; 1991). The two levels of
error include (a) the capacity to cause error and (b)
an error occurred. Harm is defined as “impairment
of the physical, emotional, or psychological function
or structure of the body and/or pain resulting there-
from” (NCC-MERP, 1991, p. 1). Nine categories of
harm range from no harm (category A) to death (cat-
egory I). These broad categories are useful for quality
benchmarking among hospitals, but research is
needed to evaluate how these categories relate to the
scope, severity, and long-term outcomes of pediatric
fall-related injuries.
A NEW PARADIGM
Our interdisciplinary team from the disciplines of
nursing, biomechanical engineering, kinesiology,
medicine, human factors engineering, forensic bio-
mechanics, and statistics proposes a momentary
confluence of events model to identify, organize,
and study factors that contribute to pediatric patient
falls and injuries. At the core of the model are fall
episodes and fall-related injuries (Figure 1). The
unique aspects of our model originated from an
extensive review of adverse event reports and
medical records from over 400 pediatric patients
who fell in our hospital between 2002 and 2009. A
striking observation was that each fall was preceded
by two or more events that occurred at the same, brief
moment in time. In the landmark book, Human Error,
Reason (1997) noted that simultaneous weaknesses
in two or more human, environment, and/or system
factors lead to a trajectory of accident opportunity.
Human factors engineering principles and methods
(Gosbee, 2010) are applicable to the problem of
pediatric patient falls and injuries. Graf (2011) used
the terms intrinsic and extrinsic factors associated
with falls. We propose that the most basic and essen-
tial intrinsic factors that determine when a child will
fall and the severity of injury are child human
factors, environmental human factors, and biome-
chanical factors (Figure 1, Table 1). Extrinsic factors
that contribute to the likelihood of a fall and injury
are parent human factors, hospital caregiver human
factors, and visible and latent system factors. Five of
the seven components of our model are consistent
with the Joint Commission’s patient safety event
taxonomy and root cause analysis methodology
(Chang, Schyve, Croteau, O’Leary, & Loeb, 2005),
and with a pediatric patient safety taxonomy devel-
oped by Woods and colleagues (2005). We added
biomechanical factors to better understand the mecha-
nisms of falls and injury due to falls, and parent
N. A. Ryan-Wenger and J. S. Dufek Interdisciplinary Momentary Confluence of Events Model
5Journal for Specialists in Pediatric Nursing 18 (2013) 4–12

human factors to the model because parents are
present during the majority of pediatric patient falls.
The multifaceted complexity of a pediatric fall event
requires an interdisciplinary team who share their
unique knowledge, research methods, and interpre-
tive perspectives to solve this clinical problem with a
new, bold, and improved view (Hanover Research
Council, 2009).
INTRINSIC HUMAN PERFORMANCE COMPONENTS
OF THE MODEL
Child human factors
Published research shows that of all children who
fell in the hospital, 31.4–62.5% were standing,
walking, or running prior to the fall, and 24–65.9%
fell from a bed, crib, or other furniture (Banco &
Powers, 1988; CHCA, 2009; Levene & Bonfield,
1991; Schaffer et al., 2011). Age and developmental
achievements are significant child human factors. As
children grow, they develop “prospective control” of
their bodies that involves “. . . detecting upcoming
threats to balance, selecting appropriate locomotor
strategies, and modifying them continuously” (Joh
& Adolph, 2006). It is normal for children to take
risks to advance their mobility development. Chil-
dren’s cognitive abilities influence their awareness
of threats to balance, and language development
influences children’s ability to summon assistance
when needed. Labeling falls as “developmental” or
“horseplay” does not absolve the hospital from the
responsibility to prevent or minimize injuries from
these falls. Added to their normal propensity to fall,
hospitalized children’s medical conditions, treat-
ments, and medications may compromise their
usual developmental and prospective control abili-
ties. This temporary developmental deficit is a sig-
nificant fall risk factor that appears in various forms
in most pediatric fall risk scales, typically scored as
yes or no. Most hospitalized children would be scored
yes on this factor. The severity of injury from falls is,
in part, a function of children’s anthropometric
characteristics, including height, weight, and body
mass, and center of gravity. Recent research shows
that obesity increases the incidence of fall-related
injuries and the severity of outcomes in children
(Morrison & Christoffel, 2008; Zonfrillo et al., 2008).
Schaffer and colleagues (2011) found that hospital-
ized children injured from falling were an average of
7 lbs heavier than uninjured children. Other child
human factors that may be related to falls and inju-
ries are listed in Table 1.
Environmental human factors
Human–machine–environment interactions are at
the root of most pediatric hospital falls. In this
context, machines are characteristics of the environ-
ment with which children interact (International
Ergonomics Association, 2000), some of which
might be disorienting or frightening to a child. In
hospital environments, many unfamiliar sounds
and objects surround the children. At times, hall-
ways and rooms are crowded and cluttered. Com-
peting environmental human factors that children
perceive may include noise, ambient temperature,
Child
Human Factors
Environmental
Human Factors
Biomechanical
Factors
Parent
Human Factors
System Factors
Caregiver
Human Factors
Falls and
Injuries
Figure 1 Interdisciplinary Momentary
Confluence of Events Model for Research on
Pediatric Patient Falls and Fall-Related Injuries.
Note: Ellipses represent intrinsic factors, and
rectangles represent extrinsic factors.
Interdisciplinary Momentary Confluence of Events Model N. A. Ryan-Wenger and J. S. Dufek

and lighting. Hospital furniture is implicated in
most pediatric patient falls. Nearly half of the
patients in several studies fell from their cribs when
a side rail was down (35.4 in.), climbed over the
crib side rails when they were up (58.7 in.), or fell
off their height-adjustable beds (19.7–37 in.) or
examination tables (30.3 in.; Banco & Powers,
1988; CHCA, 2009; Levene & Bonfield, 1991;
Schaffer et al., 2011). Hospital floors are typically
concrete covered by ceramic tile, or thin layers of
laminate, vinyl, or commercial carpeting. The
extent of injury from a fall is, in part, a function of
the surface coefficient of restitution, or “stiffness”
of the surface, which reflects the amount of energy
absorbed by the floor–person system (Bertocci
et al., 2004; Chalmers et al., 1996; Mott et al.,
1997). Less severe injuries occur on softer surfaces
with lower coefficients of restitution because more
energy is absorbed by the person–floor system.
These principles were used to develop voluntary
standards for public playground surfaces (ASTM
International, 2009), but there is no evidence that
healthcare facilities consider injury potential
in their selection of flooring materials. Other
examples of environmental human factors are
listed in Table 1.
Biomechanical factors
According to Newton’s laws of motion, that is,
inertia, acceleration, and action–reaction, biome-
chanical phenomena, including falls, are events
Table 1. Suggested Components of the Interdisciplinary Momentary Confluence of Events Model to Explain, Minimize, and
Prevent Pediatric Patient Falls and Fall-Related Injuries
Intrinsic factors Examples
Child human factors
Within 24 hr prior to
the fall
Age, sex, developmental level, height, weight, body mass, diagnoses, medications, treatments, visual deficit,
history of seizures or syncope, attention deficit disorder, hyperactivity disorder, activities of daily living
patterns, elimination patterns, gross motor achievement, gait, balance
At the time of the fall Hours post-anesthesia, hours post-sedation, acuity of illness, level of awareness, temporary illness-related
developmental deficit level, emotional status, restraints applied, activity, body position, body parts that
contacted object/surface
After the fall Position, level of awareness, activity, emotional status
Environmental human factors
At the time of the fall Time of day, presence of other individuals, location, ambient lighting, ambient temperature, noise,
accessibility of call light, object/surface child fell from, condition of object/surface child fell on, height of
fall, stiffness and thickness of contact surface
Biomechanical factors
At the time of the fall Somatotype, center of gravity above contact surface, estimated impact time (t2 - t1), acceleration,
deceleration rotation, angular or linear velocity, friction, system energy, kinetic energy, coefficient of
restitution of contact surface, surface–child contact force, tissue tolerance, head injury criteria, estimated
cranial deformation
Extrinsic factors Examples
Caregiver human factors
At the time of the fall
Presence, attitude, stress, perceived workload, inattention, distraction, multitasking, habit, boredom, fatigue,
lack of skill, cognitive overload, misleading information, poor judgment, faulty decision-making, working
in an “automatic” cognitive mode, confusion
Parent human factors
At the time of the fall
Presence, attitude, activity, stress, fear, sleep deprivation, inattention, distraction, multitasking, boredom,
fatigue, lapse, confusion
System factors Patient unit, time of day (shift), hospital and unit culture of safety, staff satisfaction, work environment,
staffing levels, skill mix, interruptions
Fall outcomes Examples
Type of fall Mechanism (drop, slip, trip, loss of balance), fall from a height, fall from standing
Fall-related injury Physical evidence (redness, swelling, bruise, hematoma, scrape, laceration, strain, sprain, fracture), results of
diagnostic tests, treatments
Level of harm and severity
of injury
Level of error, level of harm, severity of harm, age-appropriate Glasgow Coma Scale score, head injury
criteria score
Long-term outcomes Prognosis, follow-up plans
Evidence of physical, psychological, or social sequelae from a fall
Post-concussion signs and symptoms

that occur over a very short period in time, often in
less than 100 ms. Biomechanical engineers employ
forensic accident reconstruction methodologies to
evaluate the magnitude of forces applied to a
child’s body from a fall, and to estimate tissue
damage or injury potential (Klinich, Hulbert, &
Schneider, 2000). Data from fall episode-specific
child human factors and human environmental
factors are used to build a customized computer-
assisted anthropometric model. Somatotype is
derived from the child’s height, body mass index,
age, and sex, and other estimates from the
AnthroKids anthropometric database (Ressler,
1977). Additional human factors that contribute to
injury are the child’s actions just prior to the fall,
such as grasping, rolling, or turning. The site at
which the child’s body contacted the floor, for
example, anterior, posterior, right, or left side,
may require addition of a rotational component
(angular velocity) to the calculation, introducing
angular as well as linear momentum. The measure
of inertia is estimated from the literature (Jensen,
1986a, 1986b). Each of these factors is used to
estimate the body’s velocity at contact with the
surface, the momentum of the system, and the
force of contact and impact time, which is mea-
sured in milliseconds. The extent of tissue damage
can be estimated from these data.
The severity of injury is estimated from several
variables, including the force of contact, known facts
about the body part that contacted the surface, the
coefficient of restitution of the impact surface (Bates,
1999; Hannon & Knapp, 2008), and in the case of
head injury, an estimation of cranial deformation
(Bertocci et al., 2004). The head injury criterion
(HIC), a function of head acceleration rate and the
duration of acceleration, is an estimate of the poten-
tial for concussion or traumatic brain injury from an
impact (Allsop, Perl, & Warner, 1991; Holck, 2005).
HIC15 is the maximum allowable head acceleration at
the center of gravity of the head when time to
impact is Յ 15 ms (Eppinger, Sun, Kuppa, & Saul,
2000). For an adult, a HIC15 of 500 is associated with
a 18.8 Ϯ 15.4% probability of a moderate head
injury and an abbreviated injury score of 2 + (United
Nations Economic and Social Council, 2007). The
most recent HIC15 criteria from the automobile
industry and playground safety agencies are 700 for
adults, 390 for infants less than 12 months old
(Federal Motor Carrier Safety Administration,
2012), 700 for 5- to 12-year-olds, and 570 for 2- to
5-year-olds (Huber, 2011). A biomechanical study of
adult patient falls was conducted with an anthropo-
metric testing device (ATD), also known as a crash
test dummy (Bowers, Lloyd, Lee, Powell-Cope, &
Baptiste, 2008). The ATD simulated head-first and
feet-first falls from a bed at varying heights, onto a
concrete floor covered with vinyl composition tile
and a 2.54-cm thick floor mat composed of ethylene
vinyl acetate. Calculations included acceleration,
deceleration, impact force, and HIC values. HIC
values ranged from 13.41 to 282.68 for head-first
falls onto the vinyl floor compared with 1.33–10.01
onto a floor mat. Feet-first falls resulted in vinyl floor
HIC values from 486.51 to 1,234.63 and floor mat
HIC values of 3.96–374.34. The likelihood of experi-
encing a serious head injury was significantly less
when a floor mat was in place.
EXTRINSIC COMPONENTS OF THE MODEL
Caregiver human factors
Hospitalized children are rarely alone when they
fall. Razmus and colleagues (2006) reported that 82
of 100 patient falls occurred in the presence of a
caregiver, but they did not differentiate between
staff or parent caregivers. Other authors reported
that 63%, 59%, 20%, and 65% of falls occurred in
the presence of a hospital caregiver (Cooper & Nolt,
2007; Levene & Bonfield, 1991; Neiman, Rannie,
Thrasher, Terry, & Kahn, 2011; Schaffer et al., 2011).
Hospital caregivers, typically nurses, are ultimately
responsible for the safety of their patients, but even
expert nurses who are knowledgeable and skilled
can make errors while doing routine tasks (Santell,
Hicks, McMeekin, & Cousins, 2003). Caregiver
human factors that pose threats to patient safety
include stress, heavy workload, inattention, distrac-
tion, multitasking, habit, boredom, fatigue, lack of
skill, cognitive overload, misleading information,
discrepancies, intrusions, poor judgment, faulty
decision-making, working in an “automatic” cogni-
tive mode, and confusion (Buetow et al., 2009;
Gosbee, 2010; Hall et al., 2010; Santell et al., 2003;
Scott, Rogers, Hwang, & Zhang, 2006). These factors
are known to contribute to medication errors but
have not been studied in the context of pediatric
patient falls.
Parent human factors
Authors reported that 63%, 57%, 41%, 39%, and
44% of pediatric patient falls occurred in the pres-
ence of parents (Cooper & Nolt, 2007; Graf, 2011;

Levene & Bonfield, 1991; Neiman et al., 2011;
Schaffer et al., 2011). Caregivers routinely instruct
parents about their role in protecting the safety of
their children in hospital settings. Parents are often
blamed for their children’s falls, as evidenced by a
newly developed category of fall called “parental
inattention” (Kingston et al., 2010). Yet there is
ample literature to show that having a child in the
hospital is stressful to parents; therefore, it is not
unreasonable to hypothesize that parent human
factors are similar to those of caregivers, for
example, stress, fear, sleep deprivation, inattention,
distraction, multitasking, boredom, fatigue, lapse,
and confusion (Bayat, Erdem, & Kuzucu, 2008;
Gosbee, 2010; Kingston et al., 2010; Thompson
et al., 2009). Neither caregivers nor parents can
always be attentive at the moment that fall-
contributing factors converge.
System factors
Much attention is focused on the contribution of
system factors to medical errors. Visible system
factors known to contribute to medication errors,
such as unit staffing levels, skill mix, shift, and unit
acuity levels, may also contribute to pediatric
patient falls (Buetow et al., 2009; Santell et al.,
2003; Scott et al., 2006). Latent system factors
include an organization’s culture of safety (Pizzi,
Goldfarb, & Nash, 2001) and unnoticed, constantly
changing flaws in the safety system (Fillipo &
Barnhill, 2010). A major contributor to error in
many situations is the lack of fit between technol-
ogy and human nature. Technical devices, such as
computers, IV pumps, and bar coding, are meant to
simplify or increase safety of procedures, but they
often produce the opposite results because psycho-
logical and physical human factors were not con-
sidered in their design (Gosbee, 2010; Vicente,
2006).
CASE STUDY: ACCIDENT RECONSTRUCTION OF A
PEDIATRIC PATIENT FALL
To illustrate an application of the proposed
momentary confluence of events model, we con-
ducted an accident reconstruction of a pediatric
patient fall episode from an adverse event report
and the patient’s medical records. The following
factors converged during a few moments in time: A
toddler of average height and stocky build awoke
in his crib; he was groggy from a narcotic given to
decrease his postoperative pain (child human
factors). Mother was asleep in a chair next to the
crib (parent human factor). The crib rail was down,
leaving the child exposed to a 35.4-in. drop to
the vinyl-covered concrete floor (environmental
human factors). Due to a cardiac arrest on the unit,
the number of staff was temporarily decreased, and
the potential danger of this child’s situation was
not noticed (caregiver human factor, visible system
factors). The child reached for his mother and fell
to the floor. Calculations based on biomechanical
principles revealed that the head–floor force at
impact was approximately 4.5 times the child’s
body weight, which resulted in a head injury crite-
ria (HIC15) range of values from 175 to 370 (biome-
chanical factors). An HIC15 of 390–570 is applicable
to this 21-month-old child, which suggests that
while he sustained a lacerated chin and occipital
hematoma, he may not have experienced a con-
cussion. Having his chin sutured and a computed
axial tomography (CAT) scan of his head further
traumatized the toddler. The CAT scan results were
normal. No additional follow-up on his injuries
occurred during the remainder of his hospital stay,
nor was he evaluated for the presence of concus-
sion symptoms after discharge.
CONCLUSIONS
Our interdisciplinary team developed a momentary
confluence of events model that takes into account
the complexity of a fall event, and illustrates how
several intrinsic and extrinsic factors may converge
at a moment in time to cause a hospitalized child to
fall. An empirically based taxonomy of contribut-
ing factors and outcomes of falls is essential to
provide a common interdisciplinary language.
Table 1 represents a beginning effort to develop a
taxonomy from the momentary confluence of
events model components. The ultimate utility of
this model depends upon research validation of the
proposed interactions among the model compo-
nents and their relationship to fall episodes and
injuries. The research agenda in Box 1 illustrates a
progression from systematic observation of typical
movements of hospitalized children over the
course of their illness, to further development
of the taxonomy, standardization of the adverse
event report format for falls, and statistical identifi-
cation of clusters of factors that converge during
the most common types of pediatric patient falls
and injuries.

Box 1. A Research Agenda Based on the
Interdisciplinary Momentary Confluence of
Events Model to Explain, Minimize, and
Prevent Pediatric Patient Falls and
Fall-Related Injuries
1. Conduct an observation study of motion of
hospitalized children; for example, types of
movement—standing, sitting, rolling, reach-
ing, toppling over, associated with their emo-
tions, being alone, and their interactions with
people or objects
2. Develop and validate a tool to quantify hospi-
talized children’s “temporary developmental
deficit”
3. Develop a standardized adverse event report
template for pediatric patient falls and inju-
ries and near miss falls that will address the
components of the interdisciplinary momen-
tary confluence of events model
4. Generate and validate a taxonomy of pediat-
ric patient falls and injuries based on the
components of the interdisciplinary momen-
tary confluence of events model
5. Identify meaningful clusters of factors that
converge during the most common types of
pediatric patient falls
6. Identify meaningful clusters of factors that
predict the most common types of fall-related
injuries
7. Examine the relationship among illness
acuity, fall occurrence, and severity of injuries
8. Validate the NCC-MERP ratings compared
with actual severity of injuries incurred from
falls
9. Evaluate the reliability of NCC-MERP ratings
of the level of medical error, harm, and injury
severity
10. Evaluate the likelihood of concussion (mild
traumatic brain injury) from hospitalized
patient falls
11. Develop an algorithm of intrinsic factors and
injury severity factors to determine which
children should have follow-up assessments
after discharge
12. Develop a checklist of long-term symptoms of
concussion for telephone or office visit
follow-up of children whose head or face con-
tacted the floor or object during a fall in the
hospital
13. Develop and test model-based fall prevention
interventions
14. Develop and test model-based injury preven-
tion or minimization interventions
Note: National Coordinating Council for Medica-
tion Error Reporting and Prevention (NCC-
MERP), 1991.
How might this information affect
nursing practice?
The current risk-based method of predicting which
hospitalized children are at the highest risk for
falling focuses primarily on the demographic and
clinical characteristics of the children, while fall
prevention interventions focus on instructions to
parents about fall prevention and global environ-
mental factors. Yet hospitalized children continue
to fall. We propose that most fall episodes are not
predictable in time to prevent them from happen-
ing, all hospitalized children may be at risk for
falling, and an increased emphasis on prevention
or minimization of fall-related injuries is needed.
We recommend that nurses participate in the
development of the new pediatric patient falls tax-
onomy by addressing the six components of the
confluence of events model in their adverse event
reports. Near miss falls are prime examples of the
convergence of factors that lead to a fall, but for the
quick intervention of the child or other individuals.
We recommend that near miss falls be reported as
adverse events as well. More detailed information
about the child’s position prior to, during, and after
the fall will increase the precision of accident
reconstruction calculations of tissue injury by bio-
mechanical engineers. When there is evidence that
a child’s head was struck during a fall, this detailed
information is useful to predict the severity of the
impact and concussion potential. Focused interdis-
ciplinary research based on this new model may
reveal common patterns of relationships among
components of the model that are amenable to
change. This empirical and theoretical evidence
may be useful to develop and test new interven-
tions to decrease pediatric patient falls, and to
prevent or minimize injuries when hospitalized
children do fall.
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