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Preventing patient falls: A collective effort at the Fresno Medical Center

At Kaiser Permanente, ensuring patient safety is at the heart of care. The Medical Surgical unit, 3 West, at the Fresno Medical Center has long recognized the serious implications of patient falls, which can lead to extended hospital stays, additional medical complications, and decreased patient satisfaction. In response, the dedicated nursing staff has continuously sought evidence‑based interventions to minimize these risks.

“The Med‑Surg nursing staff and care team are dedicated to keeping our patients safe,” said Lindsey Halstead, MSN, RN, NE-BC, 3 West Nurse Manager at the time of the project. “They approached this work with intention and thoughtfulness knowing that it would take a team approach to make a difference in the department.”

In early 2023, the Med‑Surg Falls Reduction Team, comprised of nurses, assistant nurse managers, clinical nurse specialists, and nurse managers, thoroughly reviewed fall data from 2022. Key areas for improvement were identified, particularly in the use of bed and chair alarms. It was discovered that these alarms were not always used effectively, leading to delays in responding to patients attempting to move unassisted.

Based on a comprehensive literature review, several targeted interventions were implemented. One significant change was the accurate documentation of Fall Scale Scores for all patients, ensuring that high‑fall‑risk patients were BEST IN CLASS promptly identified. Emphasis was also placed on purposeful hourly rounding, which includes checking on patients regularly to address their needs and ensure their safety.

Additionally, the approach to shift huddles was revamped, now including the Fall Scale Scores and room numbers of high‑fall‑risk patients in the staff assignment sheets. This change ensured that all team members were consistently aware of patients at risk, leading to more timely and effective interventions.

“We are proud of the work the Fresno Med‑Surg Unit Council has done to ensure a safe environment for our members,” said Ann Bindra, DNP, MSN, RN, NPD-BC, CCRN-K, Magnet Program Director. “The Unit Council nurses make sure to keep the patient and family at the center of our nursing practice and the reduction of falls project is one such example. The team searched the literature and successfully implemented best practices which resulted in a reduction of total falls in the 3West unit over one year.”

By March 2023, all Med‑Surg nurses had been successfully educated on these new practices, including in‑person training sessions on the updated chair alarm equipment, which proved to be more sensitive and effective. The commitment to these changes resulted in a significant decrease in the total fall rate per 1,000 patient days, dropping to an average of 1.24 over the remaining quarters of 2023.

“This initiative demonstrates the power of collaboration and continuous improvement in providing the highest quality of care,” said Wendy Gospodnetich, MSN, RN, CNS, NE‑BC, Fresno Interim Chief Nurse Executive. “The team remains committed to patient safety, ensuring that every intervention is guided by the best available evidence and their shared commitment to nursing excellence.”

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