Successful Unit level Implementation of a Hospital Policy

Purpose:
The unit had experienced an increase in the number of falls and injuries related to falls. Under the guidance of the Falls Best Practice Committee, the strategic plan was to implement measures that were found to be best practice in accordance with the literature.

Significance:
Based on research and current reimbursement mandates it is essential to create a culture that understands the importance of maintaining patient safety and optimizing their health. The increase in cost related to falls is shifting entities such as CMS to consider non payment for care post falls.

Strategy and Implementation:
Assistance from the best practice council was obtained to develop an evidence based action plan which embraced a shared leadership approach to performance improvement. The staff implemented the processes outlined by the council. Daily fall huddle rounds, lead by the charge nurse, were conducted at the beginning of each shift. All patient care staff including patient care assistants, monitor technicians, unit secretaries and other members of the multidisciplinary team participated in the daily rounds. The team's focus quickly evolved from individual accountability for fall prevention to the realization that it takes a "community" to prevent a fall. A fall risk assessment score was utilized to identify patients at risk for falls. The key points highlighted in rounds are the behavioral, physical and physiologic attributes that increase the likelihood of a patient falling.

Evaluation:
Since the measures were instituted, the unit's average fall rate is in the NDNQI lower quartile and the percent of all falls that were of moderate or greater injury severity are 0.

Implications for Practice:
A fall risk assessment score was utilized to identify patients at risk for falls. The team was reminded that all team members were responsible for a patient's call for assistance. Other fall prevention strategies were yellow socks to identify patients at risk for falls and red for patients who fell.