Addressing Dismal Fall Scores: Igniting the passion and sustaining the gain for fall prevention

Purpose:
Decreasing falls through a sustainable culture change where healthcare providers felt they can truly prevent falls has been a challenge. A successful strategy was used to improve fall prevention through engagement of clinical staff and leadership in a one day, "All Things Fall Prevention" summit.

Significance:
Preventing falls is important to patient safety. Despite 15 years of focused efforts our hospital was not consistently reducing falls to desired benchmarks. The fall prevention summit, an innovative and exciting process, developed a sustainable change in culture to prevent falls as a practice norm.

Strategy and Implementation:
Two nurse managers and 5 fall champions created a Fall Summit to identify how the current culture negatively affected fall rates. Physicians, pharmacists, nurses, and rehab therapies presented. Over 100 staff attended the summit which reviewed current practice, policy, and best practice initiatives on individual units. Action plans were created and unit leadership created accountability plans to ensure that each plan was effectively implemented on the units. In order to obtain sustainability of initial scores, Nurse Manager engagement and storytelling were key. Nurse managers modeled engagement by attending fall champions meetings and having additional steering meetings as a manager group focused on falls. Fall reviews were done meetings to inspire storytelling and create awareness of how we all could prevent a fall. The end result was a decrease from 3.41 to 2.76 falls/1000 patient days overall.

Evaluation:
Three months post summit falls decreased from 3.41 to 3.05 falls/1000 patient days. The overall annual benchmark goal of 3.17 was finally achieved. Unassisted fall rates decreased from 2.12 to 1.92 falls/1000 patient as well.

Implications for Practice:
Creating an initial passion and excitement for fall prevention was a critical factor in changing hospital wide culture. Manager engagement and storytelling is also integral to the sustained success achieved initially from the fall summit. Hospital culture change can be achieved with this strategy.