Clinical Advisor
Patricia Quigley, PhD, MPH, APRN, FAAN, FAANP, FARN
Nationally known for her extensive clinical practice, research and publications, policy influence on patient safety, fall and fall-related injury prevention, and research translation across settings of care.



Colleagues, as committed professional to advancing individualized fall and fall injury prevention programs, we dedicate our care to improving patient safety through mitigation and elimination of fall risk factors and protect patients from injury when they fall.    To further our efforts, I write to share with you that the Institute for Healthcare Improvement just published their Safer Together: National Action Plan to Advance Patient Safety, September, 2020, which includes falls.   Twenty-seven national organizations collaborated as a National Steering Committee to develop this action plan because the preventable harm for both patients and the workforce continues to show “unacceptably high rates of preventable harm”1 (p. 4).

IHI has remained bold, visionary and hopeful in their leadership to convene national leaders that can drive patient safety progress within hospitals and across the continuum of care.  They affirm that we must all commit to “create the safest health care possible.   Healthcare organizations are in different places on their respective paths, but we all have further to go and more to learn and share” 1 (p. 5).

Because HD Nursing shares this commitment and leads above other fall prevention programs due to core commitment to individualized care planning to mitigate and eliminate risk factors of falls, I believe that this action plan’s four foundational and interdependent areas essential to create total systems safety align the HD Nursing’s program model.     These four action plan areas are:

  • Culture, Leadership, and Governance
  • Patient and Family Engagement
  • Workplace Safety
  • Learning System

Within each action area are specific recommendations to advance patient safety, with a total of 17 recommendations. For the purpose of this article, I will align HD Nursing’s Fall Prevention Program with the first area to affirm HD Nursing’s leadership:

 Culture, Leadership, and Governance Recommendations:

  1. Ensure safety is a demonstrated core value. As HD Nursing engages a healthcare organization, the organization must affirm that protecting patients from preventable falls is a core value of leadership and governance.
  2. Assess capabilities and commit resources to advance safety. Upon HD Nursing contractual agreement, HD Nursing completes a comprehensive baseline assessment of each organization’s infrastructure and capacity at the organization, unit, and program levels.
  3. Widely share information about safety to promote transparency. Safety information is shared through quality improvement, intra and inter- program benchmarking, progress toward structure, process and outcome goals.
  4. Implement competency-based governance and leadership.  HD Nursing’s evidence-based educational program has competence-based criteria for program launch, oversight and sustainment, integral to its program evaluation system.

As I begin to share with you this national action plan, I invite you and your team to examine the other recommendations in each area to advance your patient and workplace safety programs, as they are inter-related, such as infection rates, safe patient and handling injuries, and fall rates.   To assist you with your patient safety efforts in concert with HD Nursing’s program support,  IHI’s national action plan includes a self-assessment tool and a resource guide,  all available here

The resource guide has key influences, implementation tactics, case examples, and additional readings – truly a wealth of information.  I hope this information is helpful to you as we together to advance our patient safety preventions.

If I can help you more, please let me know.  I am always delighted to hear from you,



  1. National Steering Committee for Patient Safety. Safer Together: A National Action Plan to Advance Patient Safety. Boston, Massachusetts: Institute for Healthcare Improvement; 2020. (Available at accessed Sept. 20, 2020
  2. National Steering Committee for Patient Safety. Self-Assessment Tool: A National Action Plan to Advance Patient Safety. Boston, Massachusetts: Institute for Healthcare Improvement; 2020. (Available at accessed Sept. 20, 2020
  3. National Steering Committee for Patient Safety. Implementation Resource Guide: A National Action Plan to Advance Patient Safety. Boston, Massachusetts: Institute for Healthcare Improvement; 202