A Successful Patient Fall Reduction Program in an Inpatient Behavioral Health Unit

Purpose:
The inpatient Behavioral Health Unit (BHU) unit had the highest number of falls in the hospital. The goals of this initiative included: decrease the number of falls and the fall rate, increase the BHU staff awareness of fall prevention, and spread this project throughout the hospital.

Significance:
From May 2010 to April 2011 the number of patient falls was 80 with a fall rate of 13.77/1000 patient days. This was of great concern to the hospital's Patient Safety Committee. The current practice of patient fall prevention in the BHU was not effective in preventing patient falls.

Strategy and Implementation:
A fall prevention initiative was developed by the BHU nurse manager and staff. Staff education and awareness was accomplished through discussion at unit meetings, posting of the monthly fall data, and daily posting of the number of Days Without Falls. Fall prevention posters were created and displayed. Each shift had a fall champion who rounded on the unit to assure fall prevention practices were in place. Staff became invested to prevent falls through these initiatives. The staff worked with a vendor to test and purchase additional bed alarms, chair alarms, self-releasing belts, fall mats with glow in the dark beveled edges, wheelchair positioners, and wedge cushions. The equipment was cataloged in a fall prevention binder that contained photos of each item, instructions for use, and where the item was located. A fall prevention competency was created which all staff completed.

Evaluation:
These interventions led to a significant decrease in the number of patient falls and the fall rate. From May 2011 to April 2012 there were 45 patient falls which was a 44% reduction in the number of falls. The fall rate decreased to 7.03/1000 patient days during this same period.

Implications for Practice:
This initiative was spread throughout the hospital. The fall binders are on all the nursing units. Another nursing unit created a fall equipment cart as a result of this project. Patient fall awareness has been raised throughout the organization and is readily adaptable to other settings.