As part of our hospital’s commitment to clinical excellence, the Emergency Department (ED) implemented a Fall Prevention Bundle designed to proactively identify and protect high-risk patients.  

The bundle includes a yellow gown, socks, wristband, and a structured escalation flyer guiding staff through room placement, assessment, sitter protocols, and escalation to restrictive interventions, when necessary. The protocol helps to identify patients at risk, real-time audits and identify gaps.  

Following implementation and further evaluation of the ED’s fall prevention workflow, the results were clear: fall rates had declined, staff engagement had increased, and the visual bundle improved communication and response times across all shifts.  

Recognizing this success, the HEROES team and the Fall Work Group have been able to adapt and implement the same workflow across adult inpatient services.  

Together, we:  

• Reviewed ED data and staff feedback to identify key success factors  
• Aligned throughput processes to ensure continuity from ED to inpatient units
• Customized the bundle for inpatient workflows while preserving core safety elements
• Facilitated interdisciplinary training and shared huddles to reinforce consistency  

This initiative exemplifies how frontline innovation, when evaluated and scaled thoughtfully, can transform care delivery across departments. It reflects our shared commitment to safety, collaboration, and professional growth — and it’s a proud moment in our journey toward Magnet excellence.