A Staff Driven Fall Prevention Initiative on a Cardiovascular Unit at Mayo Clinic Florida

Purpose:
Despite hospital-wide patient safety initiatives, such as purposeful patient rounding and activating bed alarms, the cardiovascular unit (CV) had one of the highest fall percentages in comparison to other inpatient units. Our goal was to find innovative ways to reduce the fall rate to zero.

Significance:
Patient falls can result in serious injury and death. Not only are these events distressing to nursing staff, patients and families, but it increases the financial burden to the facility. Furthermore, the Joint Commission mandates that patient safety initiatives be in place for all hospitals.

Strategy and Implementation:
The following three part strategy was devised to help reach our goal: set realistic fall free days in 30 day increments, celebrate when reaching each goal and purchase chair alarms for the unit. Implementation included staff education through meetings, emails and posters. Team leaders kept a daily record of falls. An incident report was completed after each fall and sent to the Risk Manager. The unit assistant posted the daily fall results on the CV Quality Initiative board located in the hall, as well as updating the nursing website. Simple to read graphs generated by the Risk Management department were also posted on the board. Thus, highly visible feedback was provided to everyone. Upon reaching each 30 fall free day goal staff champions awarded all team members with tokens of appreciation that included notes of encouragement, sweet treats, and pizza parties. After being endorsed by leadership staff members made the decision to purchase chair alarms for each patient room.

Evaluation:
The fall rate data was generated monthly by the Risk Management department. Descriptive statistical analysis was used. Falls on the CV unit dropped from 3.8 per 1000 patient days in 2008 to 1.9 in 2011. There were 5 fall free months in 2011. The first 3 months of 2012 were also fall free months.

Implications for Practice:
This project produced a culture change leading to highly motivated staff members responding quickly to all bed and chair alarms. A practice change resulted in placing chair alarms in all patient rooms. Furthermore, nursing leadership made the decision to place chair alarms throughout the hospital.