Patients with cognitive impairment (such as dementia, delirium, traumatic brain injury, or stroke) are particularly vulnerable to patient safety events, such as falls and medication errors. Correctly assessing a patient’s functional cognitive status and using their functional status to inform the care plan can promote patient safety.

Researchers developed a cognitive assessment tool – the Cognitive Pyramid – to screen, track, and monitor patients along a cognition continuum, make proactive changes to the care plan, and decrease the risk of patient falls.

The Cognitive Pyramid includes six levels of varying cognitive function and environmental considerations:

1. Executive function (unstructured environment)
2. Reasoning and judgement (moderately structured environment)
3. Memory/new learning (highly structured environment)
4. Environmental/special awareness (highly structured environment)
5. Attention (completely structured environment)
6. Arousal (completely structured environment)

Nurses assess the patient behaviors against the six levels of cognitive function and use corresponding interventions to improve care planning, patient safety, and reduce the risk of falls.

The Cognitive Pyramid was implemented in the existing interprofessional Rapid Safety Round process at one site in January 2012. Prior to implementation, the fall rate was 4.9 per 1,000 admissions. By December 2020, the fall rate was reduced to 0 falls per 1,000 admissions.