A multidisciplinary Falls Champion Committee launched a structured improvement plan using the Plan–Do–Study–Act (PDSA) model. Root cause analysis showed that most falls from January to May 2025 occurred between 6 p.m. and 8 p.m., often during toileting or repositioning. The team set two goals: reduce falls with injury by half within six months and achieve 90 consecutive fall‑free days by the third quarter of 2025.

Interventions began in March 2025 with a focus on zero harm. The unit introduced “Tuck‑In Rounds,” pairing nurses and patient care technicians between 6 p.m. and 8 p.m. to proactively assist high‑risk patients with toileting, repositioning, and comfort needs, addressing all five P’s — pain, position, possessions, pathway, and personal needs. Peer‑to‑Peer (P2P) audits supported consistent practice, while enhanced patient and family education and monthly data displays strengthened engagement and transparency.

Direct care nurses played a central leadership role by facilitating the Falls Champion Committee, conducting event debriefs, and completing shift audits to reinforce bundle adherence and promote a strong safety culture.

Following implementation, falls with injury dropped significantly, declining by 75% between February and June 2025. By September, the unit had achieved 70 fall‑free days and earned internal recognition for surpassing the 30‑Day No‑Fall Challenge. The results highlight how frontline‑led innovation, teamwork, and data‑driven practice can meaningfully advance patient safety.