"Fall Free Days" An Innovative Fall Prevention Strategy: The Team STEPPS Approach

Purpose:
Falls are the most common adverse event reported in hospitals. Of those who fall, 25% suffer injuries which increase morbidity, mortality and cost. Falls is an important nursing sensitive indicator of care quality. Innovative evidence-based nursing strategies are needed to prevent patient falls.

Significance:
Research has identified positive relationships between nursing "best practices" and decreased patient falls, such as: IPASS (Team STEPPS)to conduct "handoff" reports and proactive, hourly rounding. Nevertheless, little is known about how best to motivate staff to use EBP fall prevention strategies.

Strategy and Implementation:
The fall rate index (2.75) at a Magnet-designated community hospital was consistently below the NDNQI benchmmark of 3.74. Nevertheless, a "shared mental model", was needed to change existing culture and further improve fall-related outcomes. This strategy is described in Team STEPPS, a patient safety program aimed at improving communication among care providers and teamwork. In 2008, the new Nurse Manager of a Medical/Surgical Unit became interested in using the concept of public reporting of quality data as an innovative strategy to create a shared mental model among her staff members regarding the importance of preventing patient falls. Hence, she decided to post the number of "Fall Free Days" at the nursing station. Although faced with opposition from both nursing and medical staff, she persevered in her endeavor.

Evaluation:
Since initiating the "Falls Free Days" strategy, patient falls decreased over 20% and related injuries are minimal. Every clinical unit now posts "Falls Free Days" as a fall prevention "best practice" strategy. Orthopedics has not experienced a patient fall in the past 165 days!

Implications for Practice:
Public reporting of quality data can be utilized as a continuous learning opportunity in the hospital setting. It serves as a catalyst which motivates staff to use evidence-based nursing practice activities to safeguard patients.