Inpatient falls continue to be a top adverse safety event in hospitals (Coyle & Mazaleski, 2016; Hoke & Guarracino, 2016). Falls impact health care through increasing length of stay and health care cost as patients may incur injury increasing patient mortality and morbidity. (Coyle & Mazaleski, 2016; Hoke & Guarracino, 2016). Fall reduction is essential to improving patient outcomes and reducing costs incurred by healthcare institutions.
In 2016, the intermediate care unit (IMCU), 4 Heart experienced an increased number of inpatient falls. The unit had 41 total inpatient falls, seven with injury. After the analyzing the data, the root cause was determined to be an increased number of new staff, new nurses, and an accountability gap.
Methods:
An action plan was initiated in February 2017 which included an educational offering and an accountability contract. In January 2018 the action plan was updated to include mandatory education for all new staff and accountability contracts for all staff. Fall debriefing presentations were added to monthly staff meetings beginning in August 2018.
Results:
Monitoring of the interventions is ongoing. Falls with and without injury were decreased by nearly 50% by yearend 2017. Post-intervention, there were a total of 21 inpatient falls, 3 with injury. The 2018 total falls year to date are 11 including only one fall with injury.
Conclusion:
The interventions implemented improved staff accountability as well as having positive impact on patient outcomes. The culture of safety on 4HH has greatly improved as a result the interventions implemented. The leadership and staff now have a timely awareness of areas for improvement through monthly fall debriefing presentations. This intervention alone has led to an increased preoccupation with failure, sensitivity to operations, and resiliency in all staff. The unit has not only improved patient outcomes but staff are embracing the principles of a high reliability organization (HRO) through the fall reduction interventions initiated on the unit.