Cultural Transformation To Prevent Falls and Associated Injuries In a Tertiary Care Hospital

Purpose:
The inpatient falls were increasing and reached 4.0 per 1,000 inpatient days. There was also an associated increase in significant fall related injuries.The goal of our strategy was to transform the hospital's culture to one supporting staff awareness, critical thinking and accountability r/t falls.

Significance:
Inpatient falls can significantly impair a patient's healing, increase their length of stay and place them at risk for further health complications. Fall prevention protocols that are superficially adhered to by staff do little to actually reduce falls and fall related injuries.

Strategy and Implementation:
The cornerstone of this initiative was fall prevention and injury reduction through the transformation of the hospital's cutlure to one with more staff awareness, critical thinking and accountability for patient safety.This was accomplished through: 1-Documenting and quantifying inpatient falls to highlight safety awareness, identifying fall patterns, evaluating the initiative's progress by monitoring data, and quantifying protocol breaches. 2- evaluating the root cause analysis of each fall to identify missed preventive opportunities, to enhance the fall prevention protocols and to determine accountability, and 3-reviewing the preexisting fall prevention protocols to identify shortcomings and improvements. The partners in this implementation include: The Board of Directors, chairman of rehabilitation, Chief Nurse Executive, nursing department, Quality management, house staff physicians, non-nursing personnel working on impatient units.

Evaluation:
Overall inpatient fall rates per 1,000 inpatient days decreased by 50% with significant reductions in minor and moderate injury rates by 65% and 35% respectively. The associated costs were minor compared to the significant savings that resulted from fewer falls.

Implications for Practice:
Cultural transformation is a powerful tool in improving patient safety and reducing inpatient falls/injuries. The Board's leadership role and inclusion of a broad range of personnel including management, nursing and non-nursing staff is key to success. Improved patient safety is cost effective.