Interventions to Reduce Patient Falls in Acute Care Hospitals

Purpose:
A quality improvement initiative was conducted to determine the effectiveness of a fall prevention program using education and a fall prevention kit on fall reduction.

Significance:
Falls are the most frequently reported safety event among United States hospitalized patients. Falls are associated with increased risk of mortality and morbidity at an estimated cost of $20 billion a year.

Strategy and Implementation:
Eight nursing units were identified based on National Database Nursing Quality Indicators® fall rates from the four hospitals. The program included on line education, leadership training, team training exercises, and a fall prevention kit. Prior to implementation, a half day training session was held. In addition, leadership training included: rounding on nursing units to ensure fall prevention interventions were implemented and a post-fall debriefing occurred. Each unit identified a champion who had a strong commitment to fall prevention. The champion facilitated team building, change management, and was accountable for outcomes. Units prepared patient rooms displaying safe and unsafe environments. A non-reusable fall prevention kit was implemented for patients' screened as a high-risk to fall. The kit included: yellow gown, yellow wristband, yellow non-skid slippers, signage, and glow in the dark urinal for male patients.

Evaluation:
Fall rates decreased but not significantly post-intervention compared to pre-intervention(P = .134). Seventy-three nurses completed the evaluation and average mean ratings ranged from 3.39 to 3.65. Nurses liked having the fall prevention interventions available in one kit to use for each patient.

Implications for Practice:
The findings support the use of education and a fall prevention kit as effective approaches to reduce falls. While this initiative was specific to an acute care hospital setting, it is reasonable to believe that education and a fall prevention kit could be replicated in other healthcare settings.