A Solution to Sitters That Won’t Fall Short

Patient falls continue to be a leading cause of preventable injury in U.S. hospitals1.

The significant costs and risks associated with these incidents, coupled with a healthcare environment of limited resources, prompt facilities across the country to adopt fall prevention safety interventions. Assigning sitters to observe individual patients around the clock is one of the most prevalent ways to address hospital falls, but it’s not necessarily the most effective.

To create effective interventions and efficient usage of scarce resources, each facility must analyze its own particular situation when seeking an optimal solution. As a nurse manager, you play a role in shaping organizational culture and ensuring that staff members fully understand and support new patient safety measures.

By the numbers

An estimated 700,000 to 1,000,000 hospitalized patients fall each year, and as many as one third of these falls are considered preventable.2  The total direct care cost to the U.S. healthcare system for all fall events in patients age 65 and older is $34 billion annually.3 At the individual hospital level, the unreimbursed costs for treating a hospital-related fall injury range from $7,000 to $30,000, depending on the severity of the injury.4 In addition, these events cost hospitals an average of $55,000 in legal claims and proceedings.5 These financial expenses are exacerbated by the potential for further revenue loss due to reputational concerns; many facilities’ fall safety performance is publically reported information.5

New options needed

One practice to prevent patient falls is the use of sitters to conduct one-to-one direct observation of high-fall-risk patients. U.S. acute care hospitals can spend more than $1 million annually on sitters, and indications suggest this cost is increasing.6
Despite the widespread adoption of this solution, there’s little evidence to support using sitters to prevent patient falls.7 However, a simple elimination of sitters to reduce costs isn’t supported, either.7 Efforts to reduce patient falls need to focus on implementing more effective and proven fall safety measures that remove the perceived need for patient care sitters.
Sitter usage and patient safety are an intertwined narrative, and efforts to isolate one from the other ignore this reality. Hospitals seeking to reduce sitter expense must review the multifactorial nature of fall events and mindfully plan a safety program that supports fall reduction efforts. Although we all can appreciate the necessity of devising fall improvement efforts around best practices, to simply overlay a broad standard without the specific purpose to address identified fall concerns will prove ineffective.8 Successful improvement initiatives need to examine the site-specific factors and context related to these events.

Specific efforts

Recent inquiries into the use of sitters within the acute care setting uncover that reliance on constant observation may be dramatically reduced without a negative impact on patient fall rates.7,9-11 These programs incorporate nurse-managed processes regarding patient safety evaluation and sitter decision algorithms, as well as frontline staff support with requisite alternative safety technologies and resources. In some cases, these efforts have nearly eliminated sitter usage within inpatient departments, at considerable year-over-year savings and benefit to patient safety.9 However, such an effort isn’t easily deployed and requires a significant and focused commitment across all levels of the organization. A large-scale review of sitter utilization and fall safety typically begins with an inquiry from senior nurse leaders advocating for more effective methods of preventing patient falls.9,10
Other demonstrations show how similar sitter reductions are achievable despite the complexity of behavioral comorbidities. Both delirium and confusion place patients at a higher risk for falls and are conditions often cited by nurses as justification for use of patient care sitters.10 It’s imperative for nurse managers to provide proper tools and resources to direct care staff members who have limited time and typically insufficient training for managing psychiatric patients. Programs that offer specific education and real-time guidance on the consistent management of behavioral patients within the acute care setting have reduced utilization of constant observation while simultaneously reducing patient fall events.10,11
One effort implemented a psychiatric liaison nurse (PLN) role to help guide the management of medical patients with comorbid psychiatric conditions. Comparing the cost of the PLN role with the reduction of sitter hours used, the program produced an annualized operational savings of $291,168.11 Another effort involved the intentional inclusion of a delirium checklist into daily multidisciplinary rounds, which served to develop an updated care plan that evolved with the patient.10 This rounding process enhanced communication and understanding across all team members and helped identify how best to collaborate on the consistent management of patient needs.10
These studies provide a small cross section of the variability in sitter reduction design efforts. More encompassing reviews on sitter efficacy have found little evidentiary support in their use to prevent patient falls.7 Sitter programs are difficult to study, given that fall prevention programs are site-specific and targeted to the needs of individual organizations. Confounding efforts to study the effects of sitters is the high probability that healthcare organizations take a multidisciplinary and multifactorial approach to fall safety efforts.12 No two intervention programs are similar and neither are the conditions in which they’re deployed. Still, nurse leaders can review current evidence on sitter effectiveness and appreciate that there are attainable cost savings without sacrificing patient safety if sitter reduction efforts are conducted in parallel with fall prevention efforts.

Preventive measures

Similarly to sitter reduction, fall prevention is a difficult topic of study because the complex nature of falls makes isolation of confounding variables impractical.13 In addition, the heterogeneity of studied populations makes generalization of evidence difficult.7 Further complicating the evidence on effective fall prevention is the inability to randomize patients once a fall risk is identified.14 Fall prevention studies present a wide array of intervention types and study designs, resulting in ambiguous and conflicting findings.8,14-16 Although safety practices or suggested fall interventions abound, there’s no consensus on best evidence for fall prevention.13 There is, however, a discernable thread of safety influencers related to falls.
A successful strategy around patient fall prevention should include interventions related to the physical care environment, care processes, and the culture of safety.17 Considerations of the physical environment include unit layout, room design, and room clutter, although successful fall prevention efforts commonly include a focus on footwear and toileting needs.16 Quick access to identified environmental concerns, such as decluttering of the patient surroundings, ambulatory assist devices, chair alarms, and commodes, may be important tools in preventing patient falls, but passively providing this equipment is insufficient.9,14 These environmental elements must be actively utilized within the care plan. Efforts to reduce falls begin with an accurate and complete assessment that identifies the individual needs of each patient and is followed by active use of this information in formulating fall prevention care.14 RNs cite insufficient communication of the plan across shifts and among team members as a key contributor to fall events.14
Programs successful in reducing utilization of sitters in favor of more effective prevention strategies have specifically incorporated a decision algorithm guiding the usage and continuation of constant observation, as well as tip sheets on how to manage patients identified as being at high risk for falling.6,9,10 Suggestions include highly supported interventions, such as medication review practices and test of change models, where a variety of universal interventions (room location, activity aprons, patient and family education, signage, nonskid socks, proactive rounding, and so on) may be considered and implemented based on patient assessment and response.6,8-11 Effective sitter reduction and fall safety practices incorporate a team approach to fall prevention.6,9-14 These efforts include collaboration of intentional rounding by multiple staff members who share an obligation to preserve patient safety.13,14
Conceivably, it’s the communication across all team members and various shifts that preserves patient care continuity and fosters an active review and engagement with the care plan to accurately reflect the patient’s evolving needs. In this manner, ineffective strategies are identified and replaced by more appropriate interventions particular to the needs of each patient. The focused and ongoing nursing assessment on fall safety advances the care dialogue from the task of initial screening and application of blanket prevention measures to a dynamic collaboration intentionally designed around the unique needs of every patient.
This work is complicated by the variety of time demands imposed on nursing staff. The added value of updating the care plan in accordance with the evolving patient condition may be supplanted by other task constraints. Effective fall prevention strategies recognize these environmental realities and strive to address such issues.

A safety culture

Developing and maturing a shared sense of safety are critical elements in reducing adverse events within hospitals.18 A strong and committed culture of safety is the most effective means of removing anticipated barriers in fall prevention programs.15 In addition, a positive culture of safety has been shown to improve adherence to fall strategy programs, resulting in improved fall outcomes sustained over time.19
Fortunately, evidence suggests that a culture of safety can be developed and improved upon within an organization; however, similar to fall prevention efforts, blindly employing techniques without specific intent isn’t beneficial.19 Attempts to apply a nontailored approach to cultural improvement obscures the fact that organizations are unique in their experiences, resources, and internal biases. As a result, organizations must endeavor to more clearly understand staff perception of quality and safety. In this fashion, specific cultural norms and expectations that have an adverse impact on staff commitment to quality and safety can be addressed.19
Some experts suggest that building a committed culture of safety should be a holistic endeavor. Their model includes three must-have dimensions of focus for sustained cultural change: enabling (leadership behaviors), enacting (frontline safety initiatives), and elaborating (learning practices). Excluding any of these elements will likely render the overall improvement initiative ineffective.20

Leadership’s role

Promoting a sense of commitment around fall safety improvement begins with leadership. Leaders are responsible for developing strategy, aligning resources to implement that strategy, and removing barriers to implementation. Senior leaders who authentically communicate, model, and engage in safety activities provide an inspiring vision that consistently improves their organization’s cultural commitment to patient safety.20 This message of commitment is most clearly conveyed by action.
The behavior of senior leaders sets a tone for the organization and influences staff perception. Organizational leaders are in a position to address patient safety by prioritizing resources, including access to time, necessary quality improvement structures, and guidance for the development of fall prevention programs. Further, leadership engagement with fall prevention initiatives includes facilitating a strategy that fosters a thoughtful implementation plan that achieves quick gains but also maintains a focus on long-term sustainability. Leadership’s consistent attitude toward improving prevention efforts and engaging in staff rounding to maintain focus is critical to successful prevention strategies.

Frontline staff involvement

Fall safety improvements can’t be achieved without frontline action. The enacting of fall prevention initiatives ultimately rests with the organization’s clinical staff members and the individual choices they make. Implementation of evidence-based fall prevention programs will be moot if not internalized and expressed in daily staff activities. Engaged teams committed to safety make a daily practice of interdisciplinary collaboration, clear transition of care communication, and a constant vigilance to identify and resolve safety concerns.20
Specific fall safety training and education are necessary; however, such measures implemented in isolation of cultivating a caring and committed attitude among staff don’t produce enduring results.15 Regarding the perception of safety culture, it’s the frontline staff, not senior leaders, who indicate overall patient safety performance.21 Frontline staff members are likely to be more clearly aware of the safety risks facing their patients and can attest to how well the organization and its leaders appreciate and respond to these risks.21 This reality reinforces the necessity of focusing on the actual environment of patient safety and tailoring interventions to address true risk factors, not passively implementing a menu of fall prevention policies and protocols.

A learning environment

Organizations need to understand the context of patient falls to devise appropriate safety interventions. Despite the inherent heterogeneity of fall prevention programs, successful fall reduction efforts consistently incorporate postfall review sessions among the care team.16 A real-time debriefing serves to identify evolving or missed risk factors, enabling the care team to adopt safety measures accordingly. Without learning these valuable lessons, fall prevention efforts won’t focus on the causative factors of patient harm. This risks wasting limited resources and frustrating staff members who continue to implement repetitive initiatives yielding no improvement in safety outcomes for their patients.
Successful fall prevention initiatives need to mindfully plan for the utilization of fall event data. Beyond simple collection, processes need to monitor the data for correlations and trends to discern actionable information for the organization. In turn, this information can be applied to develop a formal process improvement effort aimed at more effective organizational fall prevention strategies.

Management implications

Given the ethical and moral imperative to protect patients from harm, it’s difficult to entirely dissolve sitter usage. This strategy may appear to patients, families, and staff as an effective effort to prevent falls.7,9  The barriers to development of and compliance with a sitter reduction strategy may be overcome by a parallel focus on the organization’s specific fall safety concerns.
The implementation of appropriate evidence-based practices to supplant sitter utilization is essential, although it’s important to understand that a general overlay of accepted fall prevention efforts hasn’t demonstrated effectiveness.8 Strategies need to appreciate the interplay of the physical environment and care processes, particularly the sustaining forces of organizational culture.17 A positive inclination toward patient safety can be enhanced through effective role-modeling by nurse managers and other organizational leaders, a focus on the perspectives and behaviors of frontline staff, and a commitment to understanding fall events as learning opportunities.
Although sitters may have a continued place within the hospital setting, evidence indicates that this role can safely be much smaller. Attempts to reduce sitter utilization while improving fall safety require a holistic approach, leveraging the role of the professional nurse with appropriate resources and support to prevent falls and fall-related injuries.7


  1. The Joint Commission. Sentinel event alert: Preventing falls and fall-related injuries in healthcare facilities. www.jointcommission.org/assets/1/18/SEA_55.pdf.

  2. Agency for Healthcare Research and Quality. Preventing falls in hospitals: a toolkit for improving quality of care. www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html.

  3. CDC. Cost of falls among older adults. www.cdc.gov/HomeandRecreational-Safety/Falls/fallcost.html.

  4. Spetz J, Brown DS, Aydin C. The economics of preventing hospital falls: demonstrating ROI through a simple model. J Nurs Adm. 2015;45(1):50-57.

  5. Boswell DJ, Ramsey J, Smith MA, Wagers B. The cost-effectiveness of a patient-sitter program in an acute care hospital: a test of the impact of sitters on the incidence of falls and patient satisfaction. Qual Manag Health Care. 2001;10(1):10-16.

  6. Spiva L, Feiner T, Jones D, Hunter D, Petefish J, VanBrackle L. An evaluation of a sitter reduction program intervention. J Nurs Care Qual. 2012;27(4):341-345.

  7. Lang CE. Do sitters prevent falls? A review of the literature. J Gerontol Nurs. 2014;40(5):24-33.

  8. Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67 (9):1984-1992.

  9. Adams J, Kaplow R. A sitter-reduction program in an acute health care system. Nurs Econ. 2013;31(2):83-89.

  10. Laws D, Crawford CL. Alternative strategies to constant patient observation and sitters: a proactive approach. JNurs Adm. 2013;43(10):497-501.

  11. Rausch DL, Bjorklund P. Decreasing the costs of constant observation. J Nurs Adm. 2010;40(2):75-81.

  12. Rochefort CM, Ward L, Ritchie JA, Girard N, Tamblyn RM. Patient and nurse staffing characteristics associated with high sitter use costs. J Adv Nurs. 2012;68(8):1758-1767.

  13. Christopher DA, Trotta RL, Yoho MA, Strong J, Dubendorf P. Using process improvement methodology to address the complex issue of falls in the inpatient setting. J Nurs Care Qual. 2014;29(3):204-214.

  14. Dykes PC, Carroll DL, Hurley AC, Benoit A, Middleton B. Why do patients in acute care hospitals fall? Can falls be prevented? J Nurs Adm. 2009;39(6):299-304.

  15. Tzeng HM. Nurses’ caring attitude: fall prevention program implementation as an example of its importance. NursForum. 2011;46(3):137-145.

  16. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-692.

  17. Choi YS, Lawler E, Boenecke CA, Ponatoski ER, Zimring CM. Developing a multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: a systematic review. J Adv Nurs. 2011;67(12):2501-2524.

  18. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):369-374.

  19. Black AA, Brauer SG, Bell RA, Economidis AJ, Haines TP. Insights into the climate of safety towards the prevention of falls among hospital staff. J Clin Nurs. 2011;20(19-20):2924-2930.

  20. Singer SJ, Vogus TJ. Reducing hospital errors: interventions that build safety culture. Annu Rev Public Health. 2013;34:373-396.

  21. Singer S, Lin S, Falwell A, Gaba D, Baker L. Relationship of safety climate and safety performance in hospitals. Health Serv Res. 2009;44(2Pt 1):399-421.

This article, “A solution to sitters that won’t fall short” Skip Navigation Linksby Timothy J. Bock, DNPc, MBA, RN, originally appeared in the January 2017 issue of Nursing Management © 2017 Wolters Kluwer Health.
This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 500,000 nurses since 1976 and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500.


Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)

What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 

How does a shared limit policy work?

A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

We have a shared limit policy. Are employees covered if they practice outside our office?

The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

There are plenty more where those came from.

See more FAQs

NSO Learning Center

More insights from some of the best minds in nursing.

Create effective anti-bullying policies

Workplace bullying contributes to decreased team cohesion, burnout, retention issues, and absenteeism. This article will help managers and other nurses influence policy development with suggestions on crafting usable and effective anti-bullying policies.

Creating Inclusiveness for Transgender Patients

As a nursing professional, being attuned to the needs of transgender patients helps you ensure their health needs are met and reduces the risk of legal liability.

Dispensing Alert! Dial, Set, and Lock that Dose

NSO and the Institute for Safe Medication Practices (ISMP) have teamed up to help you practice safe medication use and keep patients safe. The following is an ISMP Medication Safety Alert from the August 2017 NSO Risk Advisor.

Do Not Let “Depo-” Medications Be a Depot for Mistakes

NSO and the Institute for Safe Medication Practices (ISMP) have teamed up to help you practice safe medication use and keep patients safe. The following is an ISMP Medication Safety Alert from the May 2017 NSO Risk Advisor.