Weekly Falls Review Team: Nurse-Driven Interdisciplinary Initiative to Decrease Patient Falls in the Acute Care Setting

Purpose:
Improve patient outcomes by reducing patient falls and associated costs to the patient and the hospital through the implementation of an effectively designed interdisciplinary evidence based initiative. Achieve a patient fall rate that correlates positively with NDNQI goals.

Significance:
Nurses demonstrate their impact as patient advocates by leading the design and implementation of an innovative fall prevention program. It exemplifies an effective interdisciplinary approach which, applied in any setting, incorporates each discipline's unique view of fall analysis and prevention.

Strategy and Implementation:
Adopting an EBP Fall Prevention Protocol and establishing a Weekly Falls Review Team with interdisciplinary partners. This innovative weekly meeting reviews every fall. To identifty contributing factors, nurses discuss the patient's history, reason for admission, fall risk assessment, implementation of fall prevention strategies as outlined in the protocol, and the events surrounding the fall. The Pharmacist reviews medications received by the patient. The Plant Operations Manager reviews the functionality of fall beds, alarms, and other patient equipment. Staffing effectiveness is evaluated, as is the extent of patient and family fall prevention education. Commonalities identified led to improved accountability of nurses, implementation of additional strategies such as hourly rounding and toileting, considering secondary diagnoses in the fall risk, bed alarms for patients at high risk, ensuring these patients ambulate with assistance and are never left unattended in the bathroom.

Evaluation:
Since implementation of a Falls Prevention Protocol, focused falls education for all hospital employees, and inception of an interdisciplinary weekly review of all patient falls led by the nurses caring for the patient, our hospital has had >50% decrease of patient falls in the past six quarters.

Implications for Practice:
Data indicated no correlation between time of day, day of the week, or patient age and their associated risk for falls. It has been the individual nurse's accountability for the patient's safety and implementation of specific strategies that had the greatest impact on preventing patient falls.