Critical Review of Published ArticlesAccording to the syllabus, .docx

Critical Review of Published Articles
According to the syllabus, MGMT 650 students are
… required to complete a critical review of one research
orientated journal article. The article will be selected by the
student with approval of the instructor from peer-reviewed
journals in an area of interest to the student. The article
reviewed will use descriptive statistics that the student has been
exposed to in the first 4 - 6 weeks of this course. Students will
choose articles to review from UMUC’s library resources.
For the article, students may select a topic of their interest. The
empirical research article, “Academic procrastination and
statistics anxiety” used for Sessions 1 and 2 Discussion
assignments (see Conferences section), is an example of a
descriptive statistical research article. In addition, the students
are encouraged to use UMUC’s Library to locate an empirical
research article. Finally, the instructor of the course must
approve the article. Students should upload the pdf version of
the article in the Workbook section of the online class.
Empirical Research Articles
If you never read an empirical research article, the following
web sites will help you to understand the difference between a
primary empirical research article and a secondary article:
1. http://www.nsu.edu/library/pdf/EmpiricalResearch.pdf
2. http://www.up.edu/showimage/show.aspx?file=12944
APA Writing Style
To help with the organization of the critique information in the
5- to 7-page report, the students are required to use APA format
6th edition with headings and subheadings.
Critique Report Format
The critique report format was adapted from the University of
Michigan web site:
http://open.umich.edu/sites/default/files/Topic8Assignment-

CritiqueArticle.pdf.
1. Title page, which includes (a) title of the empirical research
article and author’s name(s), (b) your name, (c) Turnitin
reliability index score, (d) running head with continuous page
numbers, and (e) date. The title page does not count towards the
5- to 7-pages for the critique report.
2. Problem statement and purpose (Answer the following
questions; however, do not write the questions in the report.) In
addition, from the empirical research report, include the page
number(s) to answers the questions:
a. What were the purpose and/or problem of the research study?
b. What are the independent and dependent variables of the
study? Correctly, identify the independent and dependent
variables.
3. Review of literature and theoretical framework (Answer the
following questions; however, do not write the questions in the
report.) In addition, from the empirical research report, include
the page number(s) to answers the questions:
a. What concepts/theories are included in the review? Please
explain them.
b. Did the author discuss the independent and dependent
variables? If so, provide examples from the literature review.
4. Hypotheses and/or research questions (Answer the following
questions; however, do not write the questions in the report.) In
addition, from the empirical research report, include the page
number(s) to answers the questions:
a. What hypothesis/hypotheses and/or research question(s) are
stated in the study?
b. Is the hypothesis(es) or research question(s) testable? Please
explain.
5. Sample population (Answer the following questions;
however, do not write the questions in the report.) In addition,
from the empirical research report, include the page number(s)
to answers the questions:
a. How was the sample selected? Please explain.
b. Which sampling method was used (probability or

nonprobability)? Please explain.
c. Was the sample size appropriate? Please explain.
d. What are the limitations of the sample population? Please
explain.
6. Research design (Answer the following questions; however,
do not write the questions in the report.) In addition, from the
empirical research report, include the page number(s) to
answers the questions:
a. Which type of research design was used? Please explain.
b. Does the research design support the hypothesis(es) and/or
research question(s)? Please explain.
7. Data collection (Answer the following questions; however, do
not write the questions in the report.) In addition, from the
answers the questions:
a. How was the data collected? Please explain with example(s).
8. Analysis of data. (Answer the following questions; however,
do not write the questions in the report.) In addition, from the
answers the questions: What level of measurement was used to
measure the variable(s)? Please explain. Which descriptive
statistical was used for calculation? Please explain with
example(s). If tables and/or figures were used, did they
appropriately illustrate the statistical results of the collected
data? Please explain.
9. Conclusion/Discussion. (Answer the following questions;
however, do not write the questions in the report.) In addition,
from the empirical research report, include the page number(s)
to answers the questions: Was the hypothesis(es) and/or
research question(s) supported or not supported? Please explain.
What were the validity threats to the study? Please explain.
10. Recommendations. If you were to conduct the study, please
explain the changes you would make to strengthen the validity
of the study.
11. Reference section. This section only applies if you cite
other sources in the critique report. In addition, the Reference

section does not count towards the required 5- to 7-page for the
critique report.
O R I G I N A L A R T I C L E
Pediatric inpatient falls and injuries: A descriptive analysis
of risk factorsjspn_315 10..18
Patricia L. Schaffer, Nancy M. Daraiseh, Lynn Daum, Ed
Mendez, Li Lin, and Myra Martz Huth
Patricia L. Schaffer, MSN, RN, is a Clinical Program Manager;
Nancy M. Daraiseh, PhD, is a Research Scientist; Lynn Daum,
BSN, RN-BC, is a Decision
Support Analyst; Ed Mendez, MPH, RN, was a Clinical Program
Manager; Li Lin, MS, is a Statistician; and Myra Martz Huth,
PhD, RN, FAAN, was the
Assistant Vice President, Research and Evidence-Based
Practice, Center for Professional Excellence, Cincinnati
Children’s Hospital Medical Center,
Cincinnati, Ohio, USA
Search terms
Fall prevalence, fall prevention, fall risk factor,
hospitalized children’s fall.
Author contact
[email protected], with a copy to the
Editor: [email protected]
Disclosure. The authors report no financial

interests or potential conflicts of interest.
First Received June 21, 2010; Revision received
May 18, 2011; Accepted for publication July 29,
2011.
doi: 10.1111/j.1744-6155.2011.00315.x
Abstract
Purpose. This study identified patient characteristics and
environmental
factors related to falls and injuries at one pediatric hospital.
Design and Methods. This descriptive study was part of a
multisite study
based on inpatient pediatric falls reported over a 6-month
period.
Results. Fall prevalence was .84/1,000 patient days. Thirty-one
of the 53
falls (58.5%) resulted in injury; 17% required treatment. Of the
injured
children, 83% were developmentally appropriate, 58% were in
the hospital
room, and five fell from a bed.
Practice Implications. Comprehensive fall prevention programs
are
required to promote patient safety.
Falls are the leading cause of nonfatal injuries treated
in emergency departments in the United States
(Centers for Disease Control and Prevention—
Injury Center, 2007). Statistics identified that in
children from birth to 19 years old, there were

more than 2 million falls a year (Centers for Disease
Control and Prevention—Injury Center, 2007).
Therefore, children’s falls are a safety concern.
As nurses, this leads to the question: Do we need
to be concerned about children’s falls in the
hospital or is it part of normal childhood growth and
development?
Children’s falls have the potential for injury and
other negative patient outcomes (e.g., increased
length of hospital stay and increased costs). When
hospitalized, it becomes the healthcare profession-
al’s responsibility to keep the patient safe. This is not
limited to medication administration and treatment
modalities but to all hospitalized patient experiences
that have a potential risk for harm. Patient safety
must be a priority for all healthcare professionals.
The Joint Commission on Accreditation of Health-
care Organizations (2010) recommends a proactive
approach to safety risks by assessing for fall risk and
by implementing strategies to prevent falls.
This study describes fall events at a free-standing
pediatric academic medical center and was part of a
larger multisite study developed by Child Health
Corporation of America (CHCA). The overall
purpose of the multisite study was to identify the
patient characteristics and environmental factors
related to falls. Additionally, the investigators will
describe in this paper the factors that differed
between the injury-related falls versus noninjury-
related falls in the hospitalized children.
THEORETICAL FRAMEWORK

Concepts from the Neuman (1995) model provided
the overall framework for organizing and structur-
ing the study with the systems of environment and
client. This structure assisted us in describing and
understanding the nature of children’s falls and
injuries. Neuman described three environmental
forces that impact the client (child): internal,
created, and external environments (see Figure 1).
Journal for Specialists in Pediatric Nursing
10 Journal for Specialists in Pediatric Nursing 17 (2012) 10–18
© 2011, Wiley Periodicals, Inc.
mailto:[email protected]
mailto:[email protected]
Major variables contained in the client/internal
environment include demographics such as age,
weight, gender, and race. Other concepts are the
child’s developmental status, level of consciousness,
mental state, and level of mobility. The internal
environment and client have a reciprocal relation-
ship and may be positively or negatively affected by
each other (Neuman, 1995).
The environment or influences surrounding the
client include the created and external environ-
ments and are viewed outside of the child’s control.
In this study, the created environment has been con-
ceptualized as the factors that were imposed upon
the child that could increase or decrease the risk for a
fall. For example, nurses’ fall prevention interven-
tions may decrease fall risk, whereas anesthesia,
sedation, and intravenous tubing can increase the

risk of a fall. The external environment consists of
variables that may contribute to the client’s line of
resistance (i.e., the location, source of the fall, and
surface conditions). The interactions of these envi-
ronments may result in increasing or decreasing the
risk for a fall and the potential for injury as a result.
BACKGROUND/LITERATURE REVIEW
More than three decades ago, the literature
described falls in hospitalized children (Helfer,
Slovis, & Black, 1977). Helfer and colleagues (1977)
reviewed hospital incident reports involving the falls
of children 5 years old and younger. Over a 6-year
period of time, there were 85 incidents of children
falling from a bed, crib, or examination table. Seven-
teen of these children were reported to have cuts,
scratches, or epistaxis; 20 children had a bump or
bruise; and one child had a fractured skull. In the
1990s, several other studies reported skull and
clavicle fractures from falls in hospitalized children
younger than 6 years (Levene & Bonfield, 1991;
Lyons & Oates, 1993). A limitation of these studies
was that they lacked reported rates.
Thirty-three years after the publication by Helfer
and colleagues (1977), there has been a renewed
interest in children’s falls and fall prevention. In
part, this interest has been driven by regulatory
and public health agencies who are expecting
healthcare facilities to reduce the risk of patient
harm resulting from falls (Centers for Disease
Control and Prevention, 2009; The Joint Commis-
sion on Accreditation of Healthcare Organizations,
2010). The purpose of the subsequent review was

to present studies that identified the prevalence
and environment surrounding pediatric falls in
hospitalized patients.
Razmus, Wilson, Smith, and Newman (2006)
identified episodes of disorientation and fall history
as best predictors in hospitalized children using vali-
dated adult-risk scales. A retrospective chart review
was conducted on 100 identified fallers and 100
non-fallers. The majority of the sample was White
(78%) males (58%). In the group of fallers, in 83%
of the time, family members were present at the
time of the fall. Falls occurred most often on pediat-
ric inpatient units (81%), in the child’s room (87%),
and when the child was going to the bathroom
(22%). Thirty-five percent of the time the equip-
ment involved in the fall was a bed and was most
often an adult-size bed (87%). Statistically signifi-
cant predictors for pediatric falls were episodes of
disorientation and fall history.
Outcome (Primary)
Fall
Injury
Outcome (Secondary)
Treatment for Injury
External
Environment
Created
Environment

Client/
Internal
Environment
Figure 1 Theoretical Framework.
Note: Content from the Neuman (1995) Systems
Model.
P. L. Schaffer et al. Pediatric Inpatient Falls and Injuries: A
Descriptive Analysis of Risk Factors
11Journal for Specialists in Pediatric Nursing 17 (2012) 10–18
Another study described inpatient and outpa-
tient falls before and after implementation of a
house-wide falls prevention program (Cooper &
Nolt, 2007). Data were obtained from both a retro-
spective and a prospective review of fall-related
events. Pre-implementation of the falls program
revealed 214 falls over a 26-month period of time
(average of 8.2 falls per month), and, during post-
implementation, 57 falls were reported over 6
months (average of 9.5 falls per month). The most
notable difference was that prior to the prevention
program, falls were more prevalent in males (63%)
than females, but after the initiation of the
program, more females (55%) fell. There was little
difference in percent of total reported falls between
pre- and post-implementation in regard to age-
groups and settings (inpatient versus outpatient).
A noted difference, during pre-implementation,

was that the majority of falls were reported in
the emergency department (34%), yet during
post-implementation, the majority occurred
on the general pediatric unit (18%). No injuries
were reported pre-implementation, but post-
implementation, 51% of the falls resulted in a
minor injury (e.g., abrasion, bruise, and hema-
toma), and two required sutures. The authors did
not report any pre-implementation injury rates.
Comparisons between groups were difficult
because of the differing periods of time (26 months
versus 6 months) for data collection and unre-
ported statistics.
Monson, Henry, Lambert, Schmutz, and Chris-
tensen (2008) described the incidence of neonatal
hospital falls. The descriptive retrospective data in
this study were collected from electronic health
records and paper risk-management records of
88,774 neonates in an 18-hospital healthcare
system. During a 36-month period of time, 14
infants sustained a hospital fall. The estimated inci-
dence was 1.6 falls per 10,000 live births. Seven of
the 14 falls were the result of a parent falling asleep,
and the majority of these falls occurred between
1:30 and 9:00 a.m. The other falls occurred in the
delivery room, hallway, and from an infant swing.
No deaths occurred as a result of an infant fall;
however, one neonate sustained a skull fracture.
Most recently, CHCA utilized a survey to obtain
information about the fall practices of member pedi-
atric hospitals. The response rate was 69%. Twenty-
eight of the 29 participating hospitals reported that
pediatric falls were tracked in their organizations.
This survey illuminated the lack of standard defini-

tions for pediatric falls, variation in fall classification,
and fall rates. Risk identification was reported by
89% of hospitals. While 81% reported using an
institution-developed tool, the other six hospitals
reported using a validated fall risk-assessment tool.
Strategies to prevent pediatric falls varied among the
pediatric hospitals (CHCA Nursing Falls Study Task
Force, 2009).
In summary, the findings from these pediatric fall
studies provide evidence that falls continue to occur
not only in hospitalized children and adolescents but
also in neonates. Reported injuries ranged from
bruises and lacerations requiring sutures to skull
fractures. The majority of studies reviewed used ret-
rospective chart reviews to obtain data. The litera-
ture also reports that further attention is needed in
the use of pediatric risk-assessment tools and hospi-
tal fall prevention initiatives.
METHODS
The research questions that guided this study
were (a) What demographic and environmental
characteristics describe hospitalized children’s falls
and resulting injuries? and (b) What risk factors
and outcomes describe hospitalized children’s
falls and resulting injuries?
Sample/setting
A retrospective, descriptive design was used. All
patients with fall events reported over a 6-month
period were evaluated for inclusion in the study. For
the purpose of this study, a fall event was defined as

“an unplanned descent to the floor with or without
assistance” (American Nurses Association, 1996).
Eligibility requirements for this study included all
fall events experienced by inpatients (medical-
surgical, critical care, and psychiatric) younger than
18 years of age. Patients on residential psychiatric
units were excluded because they were not catego-
rized as inpatients. The setting was a 530-bed
quaternary-care pediatric academic medical center
in the Midwest.
Instrument
An instrument containing 70 items was used to
collect the following descriptive information on
the patient demographics, fall event, and fall risk-
assessment. This data collection tool was developed
by members of the CHCA Nursing Falls Study
Task Force and has no reported reliability or
validity. However, by virtue of consensus of nurse
Pediatric Inpatient Falls and Injuries: A Descriptive Analysis of
Risk Factors P. L. Schaffer et al.
researchers in the task force, the tool can be said to
meet criteria for content validity. The factors related
to the patient fall event included the day of the
week, time, day of hospitalization, location of the
fall, witness, adult supervision, activity at the time of
the fall, fall type, surface conditions, environmental

lighting, relation to procedures/treatments, loss of
function, and the length of stay at the time of the fall.
Patient information variables were age in years
and months, weight, gender, developmental status,
maternal race, American Society of Anesthesiolo-
gists physical status, level of consciousness, sedative
response, visual deficits, mobility, balance, history
of syncope/dizziness, history of hyperactivity/
attention-deficit hyperactivity disorder, restraint
use, and sedative/narcotic use within 4 hr prior to
the fall. Fall risk-assessment data were collected
about the risk-assessment tool, risk-alert mecha-
nism, risk documentation, and fall prevention
interventions.
Institutional review board approval was received
prior to data collection. Prior to data collection, clini-
cal staff and management were informed of the
purpose of this study, what should be reported as a
fall according to the above definition, and the expec-
tation that all falls were to be reported regardless of
whether or not an injury had occurred.
The study team was trained on the data collection
tool and the identification of inpatients who met
study criteria. Following training, four team
members independently completed the data collec-
tion tool on a patient who met study criteria to
evaluate inter-rater reliability. This was performed
twice followed by a dialogue regarding discrepancies
and responses documented on the tool. A manual of
operations was created to help team members stan-
dardize their approach to interpreting the primary
data and to provide consistent data collection. By the
third time this sample data collection was completed
with an actual patient fall, the inter-rater reliability

reached 90% agreement.
Data collection
The staff member who witnessed the fall event, or
discovered that the patient had fallen, reported the
fall. A severity level was assigned by investigators
according to the outcome of the patient fall. The
severity category labeled “major” was defined to
include injuries resulting in a fracture or sutures.
“Moderate” injuries were classified as bleeding from
any wound caused by the fall. “Minor” injuries were
defined as children who obtained abrasions, bruises,
reddened areas, contusions, and swelling or com-
plaint of pain in the affected area. The data collector
and study coordinators were notified daily of any
reported falls and reviewed the information to deter-
mine if the patient met the study criteria.
The data collector completed the data collection
form upon determining eligibility using the reported
information. Data were collected within 72 hr of
receiving the alert that a fall had been reported.
Information that was not accessible through the
initial reporting and the electronic medical record
was identified by the data collector and shared with
the study coordinators. For any missing or unclear
data, a coordinator would contact the patient care
unit within 72 hr of notification to have a brief con-
versation with the nurse who witnessed or reported
the fall or the nurse caring for the patient at the time
of this clarification call. The staff was informed prior
to the beginning of the study that they would be
contacted to clarify any missing data. These addi-
tional clarifying data were entered into the data col-

lection sheet.
Data analysis
Due to the small sample size and the low power of the
inferential analysis, descriptive and frequency analy-
ses were used to summarize the sample demographic
information and survey items. Figure 2 depicts the
distribution of sample sizes used in the analysis. A
Wilcoxon rank-sum test was used to test age and
weight differences between the two fall types (injury
versus noninjury). All the analyses were conducted
by using SAS 9.2 (SAS Institute Inc., Cary, NC, USA).
RESULTS
Fifty-three falls that met study criteria were
recorded during the 6-month data collection period.
Of the 51 patients in this study, two patients fell
twice. These falls occurred over 62,814 patient days,
which resulted in a prevalence rate of .84 falls per
1,000 patient days.
Sample characteristics
Children’s ages ranged from 4 months to 17 years
with a median of 9 years and an interquartile range
(IQR) of 2–14 years. Their weight ranged from 7.4 to
124 kg with a median of 32.4 kg and an IQR of 14.2–
53.5 kg. This sample was primarily White (67.9%)
males (58.5%) who had no history of falls (52.8%)
or seizures (84.9%). Ninety-eight percent of the

sample was alert at the time of the fall, and the
majority had a developmental status that was appro-
priate for age (79.3%). Table 1 presents a complete
description of the sample.
Demographic (client) factors
The internal environment or client comprised
person-based factors such as age, weight, gender,
race, developmental status, level of consciousness,
mental state, and mobility (see Table 1). No signifi-
cant differences were found for age, weight,
gender, and race between injured and non-injured
children. Of the 31 falls with injuries, 26 (83.9%)
involved children who were developmentally
appropriate for age, and all 31 children were alert.
The mental state of the injured children was
recorded, and only two (6.5%) children were dis-
oriented. Twenty-two (71%) of the injured chil-
dren were reported to be independent and
unassisted in their mobility.
Thirteen falls (24.5%) occurred in children
younger than 3 years old. Forty falls (75.5%)
occurred in children older than 3 years old. See
Table 1 for additional information about fallers by
age-groups.
Risk factors (created and external environments)
and injuries

According to the theoretical framework, one way risk
factors are incorporated into the created environ-
ment is through the use of fall prevention interven-
tions (e.g., footwear and risk assessment; see
Table 2). Of the events resulting in injury, four
(18.2%) were reported in children who were bare-
foot and two (9.1%) while socks were worn. Nine
(40.9%) of the injury events were not categorized for
type of footwear (reported as “unknown”). Twenty-
four (77.4%) of the 31 injury events were reported to
have used an in-house-developed risk-assessment
tool, and nine (37.5%) of the 24 assessed children
were identified to be at risk. Finally, six (66.7%) out
of nine injury events where the child was identified to
be at risk had a specific fall prevention intervention as
part of their plan of care (see subgroups depicted in
Figure 2 and Table 2). Three of the nine events where
the child was identified to be at risk did not have a spe-
cific fall prevention care plan.
Figure 2 Sample Sizes for Subgroups.
We also explored other factors in the created envi-
ronment that could potentially increase the risk for a
fall, such as time after surgery/anesthesia, sedative/
narcotic administered in the past 4 hr, and sedative
response. Of the 31 events where the child was

injured, six (19.4%) had a sedative in the 4 hr prior
to the reported fall. Eight (25.8%) of the injury
events were reported to have had surgery/
anesthesia, and six (75%) of these events were
longer than 24 hr prior to the fall. External environ-
mental factors included the location, source of the
fall, floor surface conditions, and who witnessed the
fall (see Table 3). Eighteen fall events (58.1%)
resulting in an injured child occurred in the hospital
room, and no child was dropped. Five events where
injury occurred, the child fell from the hospital bed.
The floor surface was linoleum in 12 of the injured
cases (54.6%). Of the 53 falls, 37 were witnessed
(69.8%).
The primary outcomes explored in our framework
were fall and injury. Of the 53 falls that were
reported, 31 falls resulted in an injury. Twenty-four
of the 31 falls (77.4%) resulted in a minor injury,
and seven of the 31 falls (22.6%) were categorized as
Table 1. Client/Internal Environment Factors
Total (N = 53) Injured (n = 31) Not injured (n = 22)
Age (years)a, median (IQR) 9 (2, 14) 9.5 (2, 14) 8 (3, 13)
Age-group, n (%)
Less than 1 year 2 (3.8) 2 (6.5) 0 (0)
1 year to <3 years 11 (20.8) 7 (22.6) 4 (18.2)
3 years to <5 years 5 (9.4) 3 (9.7) 2 (9.1)
5 years to <12 years 16 (30.2) 6 (19.4) 10 (45.5)
12 years to <18 years 19 (35.9) 13 (41.9) 6 (27.3)

Weight (kg)a, median (IQR) 32.4 (14.2, 53.5) 33.3 (14.8, 56.7)
26.3 (13.1, 44.4)
Gender, n (%)
Male 31 (58.5) 18 (58.1) 13 (59.1)
Female 22 (41.5) 13 (41.9) 9 (40.9)
Race, n (%)
Asian 1 (1.9) 1 (3.2) 0 (0)
Black or African American 16 (30.2) 8 (25.8) 8 (36.4)
White 36 (67.9) 22 (71.0) 14 (63.6)
Developmental status, n (%)
Appropriate for age 42 (79.3) 26 (83.9) 16 (72.7)
Delayed/mental retardation 9 (17.0) 4 (12.9) 5 (22.7)
Unknown 2 (3.8) 1 (3.2) 1 (4.6)
Level of consciousness, n (%)
Alert 52 (98.1) 31 (100.0) 21 (95.2)
Unknown 1 (1.9) 0 (0) 1 (4.8)
Mental state, n (%)
Oriented/appropriate for age 45 (84.9) 28 (90.3) 17 (77.3)
Disoriented/confused 5 (9.4) 2 (6.5) 3 (13.6)
Unknown 3 (5.7) 1 (3.2) 2 (9.1)
Mobility, n (%)
Independent and unassisted 39 (3.6) 22 (71.0) 17 (77.3)

Independent with assistance 11 (20.8) 6 (19.4) 5 (22.7)
Dependent (e.g., body cast and paralysis) 1 (1.9) 1 (3.2) 0 (0)
Pre-ambulatory 2 (3.8) 2 (6.5) 0 (0)
History of falls, n (%)
Yes 5 (9.4) 1 (3.2) 4 (18.2)
No 28 (52.8) 18 (58.1) 10 (45.5)
Unknown 20 (37.7) 12 (38.7) 8 (36.4)
History of seizure, n (%)
Yes 8 (15.1) 3 (9.7) 5 (22.7)
No 45 (84.9) 28 (90.3) 17 (77.3)
Note: aThe p-values of Wilcoxon rank-sum test for age and
weight were .9012 and .6143, respectively. Only 51 falls were
included because of the
independent requirement of the test.
IQR, interquartile range.
moderate. There were no injuries classified as

“major.” The secondary outcome was treatment for
injury; nine (29%) of the 31 falls received medical or
surgical treatment for their injuries (Table 4).
DISCUSSION
In support of prior research (Cooper & Nolt, 2007;
Helfer et al., 1977; Levene & Bonfield, 1991;
Monson et al., 2008; Razmus et al., 2006), our
results show that children are falling in the hospital
while under care for other conditions. Inpatient falls
have been identified as a significant patient safety
risk by both The Joint Commission (McGreevey,
2005) and the Institute of Medicine (Kohn, Corri-
gan, & Donaldson, 2000), underscoring the rel-
evance of these types of occurrences. Although
prevalence rates in this study (.84/1,000 patient
days) and in others (.51–.99/1,000 patient days;
Cooper & Nolt, 2007; Hill-Rodriguez et al., 2009;
Neiman, Rannie, Thrasher, Terry, & Kahn, 2011) are
less than one fall per 1,000 patient days, injuries
resulting from these falls may impact the quality of
care, length of stay, and patient/family satisfaction.
To prevent these fall occurrences and injury out-
comes, a comprehensive assessment of the factors
Table 2. Created Environment Factors
Injured
(n = 31) n (%)
Not injured
(n = 22) n (%)
Type of footwear (n = 38)

Athletic shoes 5 (22.7) 2 (12.5)
Bare feet 4 (18.2) 1 (6.3)
Slip resistant socks 1 (4.6) 1 (6.3)
Socks only 2 (9.1) 3 (18.8)
Other 1 (4.6) 0 (0)
Unknown 9 (40.9) 9 (56.3)
Was a risk tool used to
assess risk (n = 53)
Yes 24 (77.4) 16 (72.7)
No 7 (22.6) 6 (27.3)
Identified to be at risk (n = 40)
Yes 9 (37.5) 8 (50.0)
No 15 (62.5) 8 (50.0)
Specific fall prevention
interventions in plan
of care (n = 17)
Yes 6 (66.7) 7 (87.5)
No 3 (33.3) 1 (12.5)
Post surgery/anesthesia (n = 53)
Yes 8 (25.8) 7 (31.8)
No 23 (74.2) 15 (68.2)

Sedative/narcotic in past
4 hr (n = 53)
Yes 6 (19.4) 4 (18.2)
No 25 (80.7) 18 (81.8)
Sedative response (n = 10)
Minimal—normal response
to verbal commands
6 (100) 4 (100)
Moderate—purposeful response
to verbal commands with/without
tactile stimulation
0 (0) 0 (0)
Deep—purposeful response
following repeated or painful
stimulation
0 (0) 0 (0)
Table 3. External Environmental Factors
Injured
n (%)

Not injured
n (%)
Location (N = 53)
Patient room, nonintensive care 18 (58.1) 11 (50)
Patient room, intensive care 0 (0) 1 (4.6)
Other patient care area 2 (6.5) 2 (9.1)
Patient bathroom 5 (16.1) 4 (18.2)
Playroom 3 (9.7) 0 (0)
Hallway 1 (3.2) 4 (18.2)
Stairs 1 (3.2) 0 (0)
Other public area, inside hospital 1 (3.2) 0 (0)
If fell/rolled off, from what (n = 13)
Crib 1 (12.5) 0 (0)
Bed 4 (50) 3 (60)
Chair/high chair/car seat 2 (25) 1 (20)
Other 1 (12.5) 1 (20)
Environmental surface (n = 38)
Tile (porcelain/marble) 1 (4.6) 2 (12.5)
Wood/laminate 6 (27.3) 0 (0)
Linoleum 12 (54.6) 13 (81.3)

Concrete/asphalt 1 (4.6) 0 (0)
Other 2 (9.1) 1 (6.3)
Witnessed bya (n = 37)
Healthcare provider/employee 10 (50.0) 7 (41.2)
Parent/family member 8 (40.0) 4 (23.5)
Other visitor 0 (0) 1 (5.9)
Parent/family and healthcare provider 2 (10.0) 5 (29.4)
aMultiple choice question that allowed multiple entries.
Table 4. Outcomes of Falls
Injured (n = 31) n (%)
Injury severity
Minor 24 (77.4)
Moderate 7 (22.6)
Major 0 (0)
Injury require medical/surgical treatment
Yes 9 (29.0)
No 22 (71.0)
Diagnostic procedures ordered as a result of injury
Yes 1 (3.2)
No 30 (96.8)

Injury location
Head 18 (58.1)
Not head 13 (41.9)
surrounding hospitalized children’s falls is essential
to developing best-practice interventions. As
depicted in the theoretical framework (Figure 1),
the factors are client/internal, created, and external
environment and outcomes.
Our results are consistent with other studies
investigating hospitalized children’s falls, where
more than half of falls resulted in injury, and boys
fell more often than girls (Cooper & Nolt, 2007;
Levene & Bonfield, 1991; Razmus et al., 2006) with
no temporary or permanent loss of function. Nine
(29%) of our fall events with an injury required
treatment. Four “minor” injuries and five “moder-
ate” injuries required treatment. There were no
“major” injuries. However, Cooper and Nolt (2007)
reported that 7% of falls required sutures (n = 2).
and Levene and Bonfield (1991) found four cases
that resulted in fractures. Treatment of hospitalized
falls is an unnecessary addition to a patient’s original
plan of care.
Results showed that of the 17 cases where chil-

dren had fallen and were deemed to be at risk for
falling per this organization’s fall risk-assessment
tool, 53% were injured. However, of the 23 pediatric
fallers not found to be at risk, 65% (15 falls) of the
children sustained an injury. This emphasizes the
need for a more predictive tool. (This study’s tool
had a sensitivity of 44%.) This sensitivity calculation
is limited in that this organization’s fall risk-
assessment tool by hospital policy was not required
to be used in children younger than 3 years of age,
nor in psychiatric patients. Information about the
number of patients who were assessed by the risk-
assessment tool, but did not fall, was not collected in
this study; hence, specificity, positive predictive
value, and odds ratios could not be calculated. Only
two thirds of the at-risk falls with injury had the risk
documented in the patients’ medical records or pre-
vention strategies in their plan of care. More impor-
tantly, any fall has the potential outcome of an
injury; thus, increased education on the importance
of risk documentation and effective prevention
strategies in the created environment is imperative.
LIMITATIONS
The survey used in this study was developed by
members of the CHCA Nursing Falls Study Task
Force and was not reported as a tool with established
reliability and validity. The data collectors dialogued
with the staff reporting the fall to augment informa-
tion not captured on the initial report or the patient’s
medical record; yet, when the details were not recol-
lected, “unknown” was the chosen response to some
questions on the data collection form. For example,
more than one third of the patients did not have

their fall history identified and were thus marked as
“unknown.”
This study utilized a convenience sample from one
site and only included inpatients, limiting the gener-
alizability of the findings. Because data were only
collected about pediatric patients that fell, it is not
sufficient to help practitioners determine what risk
factors to optimally include in the development of a
pediatric falls risk-assessment tool. A larger multisite
study currently being conducted by a group of inves-
tigators and CHCA will better inform pediatric
centers about the risk factors that are associated with
falls in children younger than 18 years of age. This
may begin to impact the development of an optimal
pediatric-specific falls risk-assessment tool. At our
organization, prior to this study, children younger
than 3 years of age who fell without injury were
typically not reported. Although staff were
instructed to report falls in children of all ages for
this study, it is possible that falls among some of the
younger patients may not have been reported and
thus not captured during the 6-month study. Finally
due to the relatively small sample size and cross-
sectional nature of the study, no causal relationships
can be established.
CONCLUSIONS AND FUTURE RESEARCH
Several misconceptions surrounding children who
fall were challenged by results found here. Indeed,
the majority of falls and injuries occurred in patients
whose developmental status and mental state were
appropriate for their ages. Most children were alert
with no history of falls or seizures. Of the fall events
captured in this study, few children had sedatives/

narcotics in the 4 hr prior to falling. Healthcare pro-
viders may have been more vigilant of fall potential
under the circumstances mentioned above. These
findings highlight the role, or lack thereof, played by
a child’s personal characteristics in a fall or injury
event and emphasize the need to be aware of all risk
factors within a hospitalized child’s environment.
Nurses specifically need to assess and mitigate risk
factors within the inpatient room, as this study and
others found the majority of falls occurred within
the inpatient room (Razmus et al., 2006).
Results support prior studies illustrating the need
for increased research into hospitalized children’s
falls. To develop a pediatric falls risk-assessment
tool, investigators must use study designs that will
support prospective validation, sensitivity/
specificity analyses, and evaluations in more than
one population to determine if validity and inter-
rater reliability exist (Wyatt & Altman, 1995). It is
necessary to understand the positive predictive
value of a risk-assessment tool in addition to sensi-
tivity and specificity so that the tool is not falsely
identifying patients at risk who are truly not at risk.
Efforts need to be focused on the development of a
standardized tool to effectively compare falls across
healthcare institutions and one that is applicable to

infants and children of all ages.
References
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indicators: Definitions and implications. Washington, DC:
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Healthy People 2010. Retrieved from http://www.
cdc.gov/nchs/healthy_people/hp2010.htm
Centers for Disease Control and Prevention—Injury
Center. (2007). Falls: The reality. Protect the ones you love.
Retrieved from http://www.cdc.gov/SafeChild/Falls/
Child Health Corporation of America Nursing Falls Study
Task Force. (2009). Pediatric falls: State of the science.
Pediatric Nursing, 35(4), 227–231. Retrieved from
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article35227231.pdf
Cooper, C., & Nolt, J. (2007). Development of an
evidence-based pediatric fall prevention program.
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doi:10.1097/01.NCQ.0000263098.83439.8c.
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doi: 10.1111/j.1744-6155.2008.00166.x

Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (2000). To
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How might this information affect
nursing practice?
Nurses are required to provide a safe environment
for all patients, which includes the prevention of
falls. They are responsible to manage the environ-
ment to promote the highest level of patient safety
while customizing the plan of care to address the
uniqueness of the client/internal environment.
The nurse has a significant role in leading this
safety initiative through managing a comprehen-
sive fall prevention program that includes assessing
for fall risk, intervening to prevent falls, and
detailed reporting of falls to inform better assess-
ment and prevention strategies. If a patient is iden-
tified as being at risk for a fall, visual cues should be
implemented, and fall precautions should be docu-
mented in the medical record. Fall risk should be
identified during all caregiver handoffs. Selected
fall prevention strategies should be implemented
and taught as indicated by the patient condition. In
their care planning, nurses select which strategies
are appropriate for the patient, based on age, con-
dition, and risk factors.

http://www.cdc.gov/nchs/healthy_people/hp2010.htm
http://www.cdc.gov/nchs/healthy_people/hp2010.htm
http://www.cdc.gov/SafeChild/Falls/
http://www.ajj.com/services/pblshng/pnj/ce/2011/article352272
31.pdf
http://www.ajj.com/services/pblshng/pnj/ce/2011/article352272
31.pdf

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