Falls with Injury observed/expected ratio peaked in October 2023 at 1.92. The falls committee, made up of interdisciplinary team members, participated in a gap analysis to identify gaps in adherence to the fall prevention bundle.
PDSA cycles were then developed based on what was identified in the gap analysis. Key focus areas were standard work for fall risk/history of falls reviewed on all new admissions and reported out at the daily safety huddle.
Chair alarms were mounted in all patient rooms, fall prevention supplies standardized across units with an increase in par levels.
Findings from the root cause analysis from all falls with injury events were shared with the clinical nurses via SBAR format. Education was provided on the correct bed alarm use and the importance of call light responsiveness. Collaboration between inpatient nursing, emergency department, rehab services, and quality to improve handoff communication between teams.
The clinical nurse champions rounded on patients and environment, conducting patient interviews and education, identified any opportunities, created solutions, provided peer to peer feedback and knowledge sharing. To raise awareness and visibility of progress of the falls work, rubber duckies were added to the jar in the breakroom each day the unit went without a fall with injury. This improvement project has assisted with transforming culture, increasing teamwork, ownership of practice by the clinical nurses on each unit, empowerment of clinical nurses to get involved and create change, and increased staff retention.
The incredible falls work has been sustained and current data through September 2024 has the falls with injury observed/expected rate at 0.94. The 5th floor team has just celebrated 365 without a fall with injury on their unit.
The work was led by: Patricia Mittone MBA, BSN; Wei-Chien Chang, BSN, RN; Sara Stein, BSN, RN; Chavoy Kellogg, BSN, RN; Key Harper, BSN, RN; Linda Ortiz, PT; Virginia Breslo, RN; Shirley Hasson, BSN, RN; Ashley Thompson-Brundidge, MSN, RN; Cyntia Boter MSN, RN; and Alex Quiroga.
