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Appl Ergon. 2016 Sep;56:117-26. doi: 10.1016/j.apergo.2016.03.011. Epub 2016 Apr 8.

Iterative user centered design for development of a patient-centered fall prevention toolkit.

Author information

  • 1Healthcare Systems Engineering Institute at Northeastern University, Boston, MA, USA. Electronic address:
  • 2Healthcare Systems Engineering Institute at Northeastern University, Boston, MA, USA.
  • 3Brigham and Women's Hospital, Boston, MA, USA.
  • 4Montefiore Medical Center, Bronx, NY, USA.
  • 5Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.


Due to the large number of falls that occur in hospital settings, inpatient fall prevention is a topic of great interest to patients and health care providers. The use of electronic decision support that tailors fall prevention strategy to patient-specific risk factors, known as Fall T.I.P.S (Tailoring Interventions for Patient Safety), has proven to be an effective approach for decreasing hospital falls. A paper version of the Fall T.I.P.S toolkit was developed primarily for hospitals that do not have the resources to implement the electronic solution; however, more work is needed to optimize the effectiveness of the paper version of this tool. We examined the use of human factors techniques in the redesign of the existing paper fall prevention tool with the goal of increasing ease of use and decreasing inpatient falls. The inclusion of patients and clinical staff in the redesign of the existing tool was done to increase adoption of the tool and fall prevention best practices. The redesigned paper Fall T.I.P.S toolkit showcased a built in clinical decision support system and increased ease of use over the existing version.


Evidence-based fall prevention; Patient safety; Patient-centered design; RE-AIM; Usability

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