In September 2024, the Fall Prevention Rapid Improvement Event (RIE) marked a transformative milestone in patient safety at Kaiser Permanente Modesto Medical Center. Before this initiative, the Medical-Surgical Units had recorded 13 falls with injury year-to-date, underscoring the urgent need for action. Falls posed significant risks to patient recovery, impacted care quality, and highlighted the necessity for systemic improvements. Under the dedicated leadership of Lorry Quintero, MSN (Clinical Adult Nursing Director), and Sameer Khullar, DNP (Lead Quality Nurse Consultant), the RIE brought together an interdisciplinary team led by frontline nurses, to implement lasting solutions.
Through root cause analysis, the team identified key contributors, including inconsistent rounding practices, delayed responses to call lights, and environmental hazards like cluttered pathways. Using the Plan-Do-Study-Act (PDSA) framework, they introduced standardized hourly rounding to meet patient needs proactively, a “No Pass Zone” to ensure timely assistance, and targeted environmental improvements, such as decluttering and labeling mobility aids for easy access. These interventions created a culture of accountability and patient-centered care.
The results were extraordinary. Since the RIE, the Medical-Surgical Units have reported zero falls with injury, a remarkable improvement from the 13 incidents recorded earlier in the year. The accompanying graph vividly illustrates this steep decline, showcasing the sustained impact of the interventions. This success underscores the power of collaboration and innovation, led by strong, focused leadership and a dedicated team.
The Fall Prevention RIE has set a new standard for patient safety at Kaiser Permanente Modesto Medical Center and serves as a model for future initiatives. Through collaboration, data-driven strategies, and an unwavering focus on excellence, this initiative showcases that transformational change is both achievable and enduring.
