From January to August 2024, Kaiser Permanente Roseville recorded 88 patient falls across adult inpatient units, with 32 occurring on the first floor. In response, a series of targeted interventions were launched to improve fall bundle compliance and reduce falls with injury. In October 2024, Fall Kamishibai Cards, also known as K-Cards, were introduced to address inconsistencies in adherence to bundle elements. Since implementation, 1 North has gone 126 days without a fall with injury, and 1 South has achieved 235 days without a fall with injury.

Additional safety enhancements included the installation of blackjack bed connections in December 2024, which resolved bed alarm failures caused by faulty pin cords. Weekly fall calls began in November 2024 to review root causes of non-Safety Priority Index falls, fostering shared learning across adult inpatient services. In March 2025, fall management kits were developed using K-Card data to ensure consistent availability of fall magnets, non-skid socks, and fall risk wristbands.

In May 2025, the First Floor Care Experience and Falls Performance Improvement Teams collaborated to strengthen authentic hourly rounding practices and documentation of safety rounds. Over five months, the team conducted a PICOT (or Population, Intervention, Comparison, Outcome, Time question), literature review, critical appraisal, and rounding validation. A Plan-do-study-act cycle was launched to support nurse and patient care technician rounding every other hour, with daily feedback shared with staff. Since the September 1, 2025 rollout, safety round documentation has improved 8.14%, demonstrating the power of frontline engagement and data-driven practice.