Falls Reduction

Purpose:              The purpose of the macrosystem practice change project was to become a “Falls Free” Hospital.

Objective:           Engage and involve the clinical leaders of all microsystems (patient care units) in the change process and to implement the evidenced based fall   

                             reduction/safety reduction bundle.

Methodology:   Through the use of the Method for Microsystems Change Process a falls reduction plan was created utilizing the thirteen steps in collaboration and

                             commitment of all clinical leaders. The opportunity for improvement and expected outcome were identified, evidence based best practices reviewed, and

                             all hospital wide stakeholders engaged. Expected staff patient care practices were identified and the clinical policy revised substantially. The leaders

                            designed and committed and to a new practice bundle process which is summarized as follows:

1-            A fall risk assessment upon each patient’s admission, transfer, each shift and change of condition.

2-            A ‘falls report’ to identify all high risk fall patients on each unit would be printed from the clinical documentation system each shift by the Charge Nurse.

3-            A safety huddle, with all scheduled staff highlighting all of the patients considered to be a high risk for falls, would be lead each shift by the Charge Nurse.

4-            Hourly patient care rounds would be made by a nurse or certified nursing assistant.

5-            The ‘falls report’ would be reviewed by the Nursing Manager to follow-up and assure the staff were practicing the new patient care bundle.

6-            Weekly and monthly outcome reports would be reviewed by Nursing Managers.

7-            If a fall occurred, review and follow up would be provided by the appropriate Nurse Manager and a report at the monthly Falls Review Committee Meeting. The

               Nurse Manager, where a fall occurred, was accountable for appropriate counseling and possible disciplinary action per the revised policy and practice bundle.

Results:                The practice bundle went into effect ten months ago. During the first month falls were reduced by 68% from the year prior. The outcomes have been 

                              maintained for ten consecutive months.

Conclusions:     Fall reduction has continued with the comprehensive change strategy. The key difference has been the structured planning process that clearly delineated

                             the expectations and accountability for patient care practices and management.

Implications:      The microsystem practice change method contributed to the hospital’s success in assuring practice sustainability and through that, outcome

                             sustainability. A comprehensive falls reduction practice bundle may be useful to other facilities to achieve significant clinical outcomes.