Fall Prevention Best Practice Team

The Fall Prevention Best Practice Team was assembled to identify innovative approaches that could be adopted for fall prevention. Team members were from nursing staff and management, physical therapy, radiology, CNSs, and nursing research. An assessment of current practice revealed that fall risk assessments were being documented according to policy using the Hendrich II Fall Risk Assessment Tool. This did not correlate with a significant change in the rate of falls and falls with injury. The interdisciplinary team thought that the key was in the development of innovative strategies to be used when patients were identified as high risk. An extensive review of the literature related to fall prevention was completed. The literature revealed three primary interventions that have been piloted and subsequently implemented house-wide. First, was the use of colored non-skid socks for the patients. Patients identified at fall risk had received a yellow sign posted on their door, and on the front of their chart. The team believed that the addition of yellow socks would identify the patient for anyone in the hospital who interacted with that patient. If a patient had fallen in the hospital, they received red socks. Anyone seeing a patient in the hall with red socks knew they should always be accompanied and not left alone. Second, was the addition of safety huddle to the change of shift communication on each unit. The patients at high risk for falls were identified and labeled as “community property”, so every staff member responded to their call lights. Thirdly, after every fall, a fall reporting protocol that includes an immediate fall debriefing was developed. This provides critical information that is often forgotten when reporting is delayed. The heightened awareness these interventions have created has kept the staff focused on fall prevention rather than fall risk assessment.