No One Falls: Impact of a Comprehensive Interdisciplinary Falls Prevention Program

Purpose:
The purpose of this program is to illustrate how a comprehensive interdisciplinary fall prevention program decreased the number of inpatient falls and fall related injuries in an acute care community hospital by engaging all associates, patients, and families in the process of fall prevention.

Significance:
Falls are a common adverse event that can injure hospitalized patients. An injury can prolong hospitalization, compromise independence & increase hospital cost. Designing a sustainable fall prevention program is often unsuccessful due to increasing patient acuity & failure to identify risk factors.

Strategy and Implementation:
In April 2010 a 2 day interdisciplinary workout created an action plan for a Comprehensive Fall Prevention Program. The program included: an interactive education event attended by clinical & nonclinical staff;hourly rounding; new equipment to facilitate patient transfer & ambulation; gait belts & walkers available in patient rooms;improved signage for at risk patients; beds with integrated bed alarms; education on the ABCs of falls; a patient safety video; & a patient partnership agreement. A "Fall Alert" process was developed that alerts all hospital leadership of each patient fall. Then a post fall huddle occurs with staff involved with the fall & includes Rapid Response, QI, & a CNS. Post Huddle the CNE is called to discuss the plan of care & lessons learned. An ACA is conducted weekly on all patient falls; ancillary staff e.g., PT & RT is included. This engages staff & promotes awareness. Safety calendars are posted & fall free milestones i.e., "100 Fall Free Days" are celebrated!

Evaluation:
Fall rate & injury rate are calculated monthly. Control charts illustrate effectiveness. Fall chart, 9 data points in a row below the center line equaling a positive shift in process. Current rate 2.72. Injury rate decreased from 2.06 for 4/10 to 1.12 for 4/11. Post program 12 mo.injury average,0.61

Implications for Practice:
An effective fall prevention program engages staff members, as well as the patient and family. Using a fall prevention approach that is interdisciplinary and patient focused can decrease falls and prevent patient injury. Sustainable results can be achieved & translate to positive patient outcomes.