Fall Prevention: Design and Implementation of the Code Yellow Program

Purpose:
The consequences of a patient fall can be devastating. The Code Yellow program aims to reduce in-patient falls, improve patient safety, and enhance nursing knowledge about fall risk and prevention. Join me as we explore how this facility partnered with frontline staff to reduce in-patient falls.

Significance:
Patient Safety is a priority for all health care facilities; historically, falls represents the largest category of hospital incident reports (Goodridge & Marr, 2002, p. 549). Fall Prevention, traditionally, is challenging to impact and sustain.

Strategy and Implementation:
A participative approach to redesigning the Fall Prevention Program motivates employees and increases commitment. A multidisciplinary review of in-patient falls allows for open dialoguing about the opportunities and successes related to each event. Frontline staff have untapped insight in applying change at the bedside successfully and the report out process is a great avenue to disseminate information and receive valuable feedback. Code Yellow Program tools and materials will be shared. When a fall occurs, a Code Yellow is called overhead; first responders identify immediate opportunities to reduce safety and fall risks. Enhanced documentation and post-fall audit aid tracking and trending. Staff report out weekly, on falls with opportunities and falls with injury. Together we examine: What happened? What increased the patient's risk of falling? What opportunities were identified? What recommendations moving forward? and Any trends/changes to policy/process/PDSA?

Evaluation:
The Code Yellow program secured a 20% reduction in Fiscal Year 2011 in-patient falls and a reduction in the fall rate, to 2.83 falls per 1,000 patient days; a total of 44 fewer in-patient falls.

Implications for Practice:
- Participative and Multidisciplinary Fall Prevention Program - Announce a Code Yellow, post fall (post-fall team responds including Security, Patient Mobility Team, supervisor) - Formal staff report out - Dissemination of information, opportunities, and successes