The Chief Wizard of Falls (CWF): Staff Nurse Leader Role in Prevention

Purpose:
The 6 South Med-Surg combined Neuroscience Unit identified that the unit had a fall rate per 1,000 patient days over the 90th percentile compared to like hospitals. The goal of the Chief Wizard of Falls program is to achieve 50th percentile for falls per 1000 patient days within six months.

Significance:
Neurological patient falls are among the most common adverse variance events reported by nurses and staff and falls are leading cause of death. The risks of not preventing falls include: suffering and premature death due to hip fractures; traumatic brain injuries; and severe loss of independence.

Strategy and Implementation:
The intent of the Chief Wizard of Falls program was to inculcate nurse led proactive monitoring and fall prevention. Strategies included: unit fall team with membership from nurses, techs, leaders, education and therapies; fall debriefing tool with pharmacologic review of potential drugs increasing risk of falls; piloting new equipment (bed alarm pads tied to nurses station, floor pads); educational staff video highlighting each team member's role as a CWF with each patient encounter; patient education brochure; daily shift huddles directing interventions. Using a shared governance approach a team designed project plan and timeline focused on key factors for success to assure all staff understood rationale and daily workflow changes. Changes were accomplished through in-services and one-on-one peer shadowing to assure new strategy implementation. Additional training provided to transportation, dietary and housekeeping alerted unit staff when risks are identified.

Evaluation:
Over the past three months, initiatives focused on patient and staff education along with bed alarm use and response. During this time we recognized a 24% decrease in fall rates compared to the previous three month period moving quickly toward 50th percentile goal.

Implications for Practice:
Implementing CWF program can lower neuro unit fall rates by empowering nurses to adapt workflow processes and intervene at each patient encounter while engaging all team and family members. Consistent messaging for family/staff on safety awareness, environmental risks and bed alarms is necessary.