Success With a Fall Reduction Strategy

Systemic change requires visionary leadership. The board of trustees for our facility established a new three-year strategic plan based on our six indicators of success. One such indicator is Quality & Patient Safety, and the board determined that this indicator should include a vision "to eliminate all preventable harm."

Given this direction, we chose to focus on patient falls and began to ask ourselves whether we could eliminate all falls. The prior year baseline for our organization was 3.8 falls per 1,000 patient days. When compared to the National Database of Nursing Quality Indicators, we were within the benchmark for our medical-surgical units.

We still believed there was opportunity for improvement. To ensure organizational involvement, we added the organizational fall rate as part of the leadership merit-based performance management system. This includes all supervisors, directors, and the administrative team. This step was crucial to remove barriers and to demonstrate support for this common goal.

Our strategy was simple: First, we organized a multidisciplinary team to meet monthly and began to look at the data. We found that although our falls had reduced over the past five years, there was still great variability from month to month and from unit to unit. We evaluated our fall reduction policy/program and felt it was relevant and remained current to the evidence-based literature we researched, with one exception: We implemented a national strategy promoted by the Iowa Healthcare Collaborative, which was to place a yellow wristband on all patients identified as a fall risk. We then reeducated our staff on their roles and the importance of the program.

Next, we went back to the data, which we stratified manually into day of week, time of day, level of fall prevention in place at time of fall, staffing adequacy, etc. We found through our data review that 42% of our falls occurred with bathroom activities, and there was a pattern of falls occurring at change of shift.

To address these issues, we educated our nursing staff on the data and modified our hourly rounding program so nursing staff were required to assist fall risk patients to the bathroom hourly. We also adjusted change of shift activities to free up the patient care technicians so they could make bathroom rounds prior to performing their vital signs and other duties. We use shift huddles to reinforce the fall prevention strategies and report successes, as well as issues, with falls that occur.

When a fall occurs—and, yes, they do occur—we conduct an immediate root cause analysis. We evaluate whether the patient was assessed correctly and interventions were implemented, and then determine the cause variable that led to the patient's fall. Each fall is reported at the monthly meeting for further evaluation and education.

Other fall reduction strategies that we continued to utilize are as follows:

• Bed alarms. We purchased more units and increased use of the bed alarms through our call light to the two-way communication device.
• Volunteer sitter program. We are fortunate to live in a university community and have tapped into the university to establish a sitter pool for students to volunteer once provided the competency development.
• Companion program. We have hired staff to work in our float pool to function as companions for patients needing one-to-one care. The companions function as patient care technicians for the one patient assignment, thus freeing up time for nursing staff to care for other patients.
• Daily fall risk assessment and falling star program. We evaluate patients for fall risk at least once per day to see what variables have changed. In addition, if a patient has suffered a fall, we attach a falling star symbol to the outside of the patient room to alert staff to the greater potential of a repeat fall.
• Monthly celebration. We track the unit fall rates daily. The unit that goes the most days without a patient fall within the month receives a celebration.
• Poly-pharmacy review. We are implementing a poly-pharmacy review of all fall risk patients on 10 or more medications to identify opportunities to reduce the impact of medications on the patient's outcome.

The results through the first six months of this fiscal year demonstrate our fall rate as 2.8/1,000. This is a 26% reduction in falls from the previous year baseline rate of 3.8/1,000, and the monthly variation in fall rate has diminished. We have not eliminated falls, nor do I know whether that is possible; however, we are well on our way to reducing the potential of this harm for our patients.