Q 2 to Protect U: Lessons Learned in Fall Prevention Practices

Purpose:
When an inpatient medical oncology unit's fall rates, with and without injury, exceeded target goals for four consecutive quarters, it was essential to identify and develop strategies to decrease the number of falls.

Significance:
Oncology patients are at high risk for falls due to complex treatments and symptoms. Falls impact LOS, quality of life, discharge planning, and nurse-patient relationships. The institution's financial burden from treating injuries due to falls threatens ability to deliver quality care in the future.

Strategy and Implementation:
We analyzed twelve months of fall data identifying root causes and performed audits measuring compliance with policy. Findings showed staff did not perform safety checks 32% of the time, 32% of patient rooms had obstructive paths to the bathroom, staff performed safety checks with significant variance, and there was absence of shared team responsibilities and patient engagement. Literature was reviewed and 160 practices in fall prevention and reduction were ranked on feasibility and effectiveness. An evidence-based campaign was developed. It includes a slogan design, scripting, shared team responsibilities based on work flow, improved patient call and bed exit alarm systems, and patient engagement Staff completed an interactive education program. Slogan pins are worn increasing staff and patient awareness, scripting cards are worn with name badges promoting consistency in addressing the five elements of the safety checks, and a chart of accrued falls is displayed on the unit.

Evaluation:
Data collection is ongoing and first quarter analyses will be shared at the conference presentation. Reduction in falls and falls rate is the goal of successful implementation. Elimination of variance in practice and increased patient engagement will be measured by audits and patient interviews.

Implications for Practice:
Root cause analysis led us to incorporate evidence-based strategies for the development of this project. These strategies can be utilized in other patient populations and organizations to ensure a safe environment for patients.