1. Gonzalez, Jackie DNP, ARNP, MBA, NEA-BC, FAAN

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Pediatric fall events in hospitals occur because of various developmental and nondevelopmental causes, including increased activity levels, the child's health status, and contributing factors of the disease or treatment process.1 Most of the literature focused on patient safety efforts in relation to preventing patient falls has been evidenced in the adult population.2 In 2005, The Joint Commission developed a patient safety goal (NPSG9) requiring hospitals to develop a fall prevention program, regardless of patient age, that protected all patients from harm.3 The Joint Commission determined that there was no exemption for pediatrics in screening or assessing fall risk or in preventing falls.4 In addition, the American Nurses Credentialing Center (ANCC) Magnet Recognition Program(R) recognized patient falls as a nursing-sensitive indicator across organizations,5 noting that high-performing organizations outperform benchmarks.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

In 2005, Nicklaus Children's Hospital assembled an interprofessional team to study this important practice problem with the aim of addressing the new standards. With the underpinning of the ANCC Magnet Recognition Program, the team spent the next years reviewing existing, primarily adult-based literature and in developing and refining the Humpty Dumpty Pediatric Falls Prevention Program(TM). In reviewing the existing literature at the time, the Morse6 and Hendrich7 scales were the primary scales aimed at preventing falls. Most existing research addressed fall-related deaths and injuries essentially in community settings. In subsequent years, the development of pediatric tools began to emerge as well with the development of the CHAMPS [Change in or altered mental status, including episodes of disorientation (C); history of falls (H); age of less than 3 years (A); and altered mobility (M). Parental involvement (P) and safety interventions (S)] Falls Risk Assessment8 and the GRAF-PIF(TM) (General Risk Assessment for Pediatric Inpatient Falls) scale.9


After thorough review and collaboration with other institutions, the nurse-led interprofessional team of Nicklaus Children's Hospital elected to develop a unique pediatric fall prevention program named the Humpty Dumpty Falls Prevention Program(TM) (HDFPP). The HDFPP met the unique needs of children by appropriately identifying risk factors for infants and children related to falls. The program is based on a scale with specific grading criteria and stratified within 7 parameters (Figure 1).

Figure 1 - Click to enlarge in new windowFigure 1. Humpty Dumpty Falls Prevention Program(TM)-grading criteria: 7 parameters.

The outcome of the organization's innovative work is a research-based, tested program that incorporates assessment, education, and prevention strategies that have become global standards in pediatric patient care. Ten years have passed since the HDFPP began, and the Nicklaus Children's Hospital team has continued to research and accumulate evidence of the effectiveness of the program in reducing falls in children.


In 2006, the program was used by 16 hospitals. In 2016, its growth is demonstrated by its adoption in approximately 1,200 hospitals globally, including 995 organizations across all 50 states and more than 94 ANCC Magnet(R)-recognized organizations. In addition, the HDFPP is used by every branch of the US armed services and is deployed in their hospitals around the globe. In addition to English, the HDFPP has been translated into 5 languages (Spanish, French, Portuguese, Italian, and Japanese) and is used in 18 countries on 6 continents. Adoption is extensive, including Australia, where the program is implemented in more than 96 hospitals across the continent. Throughout the full deployment of the program, Nicklaus Children's Hospital experienced a steady decrease of 41% in fall rates, from 1.03 per 1,000 patient days in 2009 to 0.42 per 1,000 patient days in 2015 (Figure 2).

Figure 2 - Click to enlarge in new windowFigure 2. Nicklaus Children's Hospital fall rate trend.

Affirmation of the effectiveness of the HDFPP has been widespread. At All Children's Hospital in St. Petersburg, Florida, ambulatory services educational specialist Julie Perez, BSN, RN, reports positive outcomes since deployment, citing a 25% reduction in both the inpatient and outpatient fall rates (oral communication, August 2015). Shanon Scarisbrick, BScN, RN, a regional pediatric clinical nurse educator from Vancouver Island Health Authority Pediatrics located in Central/North Vancouver Island, Canada, stated that since 2013, the hospital has had "fewer documented falls in our patient safety reporting system since implementing Humpty Dumpty" (written communication, March 2015).


In 2015, Nicklaus Children's Hospital was awarded the ANCC Magnet Prize(R) for extraordinary innovation and its evidence-based commitment to preventing injuries from falls in hospitalized children around the globe. With the HDFPP, a challenging practice problem became the impetus for ongoing nursing commitment to attaining positive empirical outcomes that aim to ensure the safest hospital environment for children. The organization continues to develop new knowledge and is currently leading a 5-year multisite international research study regarding the specificity and sensitivity of the tool as well as continuing to collaborate with and mentor organizations around the world with the common commitment of improving patient care and safety.




1. Kingston F, Bryant T, Speer K. Pediatric falls benchmarking collaborative. J Nurs Adm. 2010; 40(6): 287-292. [Context Link]


2. Lacey S, Smith JB, Cox K. Chapter 15: pediatric safety and quality. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008; 10: 1-56. [Context Link]


3. The Joint Commission. Examining inpatient pediatric falls: understanding the reasons and finding the solutions. Jt Comm Perspect. 2005; 5: 5-6. [Context Link]


4. Fall Reduction Program NPSG-Goal 9-09.02.01. December 9, 2008. Accessed February 2, 2016. [Context Link]


5. American Nurses Credentialing Center. Magnet Recognition Program Application Manual. Silver Spring, MD: Author; 2013. [Context Link]


6. Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging. 1989; 8: 366-367. doi:10.1017/S0714980800008576. [Context Link]


7. Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003; 16: 9-21. doi:10.1053/apnr.2003.YAPNR2. [Context Link]


8. Razmus I, Wilson D, Smith R, Newman E. Falls in hospitalized children. Pediatr Nurs. 2006; 32(6): 568-572. [Context Link]


9. Graf E. Magnet children's hospitals: leading knowledge and development and quality standards for inpatient pediatric fall prevention programs. J Pediatr Nurs. 2011; 26: 122-127. [Context Link]