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Pharmacist Medication Profile Review to Decrease Hazardous Falls and Improve Patient Quality of Care as Part of a Pharmacy Fall Prevention Program

Burl G. Beasley, R.Ph., M.P.H,  Edna Patatanian, Pharm.D.


Mercy Health Center, Oklahoma City, Oklahoma

The Pharmacy Fall Prevention Program (PFPP) was designed and implemented to reduce patients’ fall risk based on their medication profile. This program includes classification of medications according to fall risk, daily pharmacist medication review, and adherence to the pharmacy fall prevention policy. 

Two clinical pharmacists who were members of the Falls & Restraints Committee (FRC) designed and implemented the Pharmacy Fall Prevention Program. They worked collaboratively to research the existence of a medication scoring system to rank patients’ fall risk. When they found inconclusive evidence of a standardized scoring system, they developed the Medication Fall Risk Score (MFRS) that categorizes drug classes which are known to contribute to increased falls  The MFRS report which lists patients at potentially greater risk for falls is generated daily. Clinical pharmacists use this report as a tool to follow patients and make appropriate patient interventions which has resulted in a reduction of hazardous falls on the Medical-surgical units. 

The greatest impact of the PFPP has been increased clinical pharmacist involvement in patient profile review and patient counseling.  Hospitalized patients receive face to face counseling from the clinical pharmacists regarding their medications and the mechanisms by which they may increase their risk of falling.  This provides patients with a better understanding of their medications as related to fall risk. In addition, working relations between physicians, pharmacists, patients, nurses, and other healthcare professionals have improved as they have worked together to provide a safer inpatient environment.  These improved relationships have also brought about an increased awareness of the association between medication use, physician prescribing, nursing assessment, and pharmacy medication review and their relationship to the patient’s risk of a hazardous fall. Monthly FRC meetings and bi-annual pharmacy patient fall risk meetings reinforce the importance of the PFPP.

The cost savings from preventing both injury falls and total falls equal approximately $216,000 per year. The cumulative dollars saved in prevented falls is estimated to be $400,000 with no negative impact on the overall financial status of this facility.  Time allotted for pharmacist review of medication profile on a daily basis is included in this cost savings estimate.

Utilization of a medication fall risk score to identify high risk medications and patients potentially at greater risk for falling has effectively improved patient safety and our institution’s overall rates of falls. Involvement of the clinical pharmacists in medication profile review has been shown to reduce harmful falls. An effective PFPP primarily focused on medication therapy review can result in significant cost savings and improved patient care. 

 View a pdf of the poster from the Midyear Meeting (2.8 MB).