I am the nurse manager of a 36-bed medical unit with a primary focus of stroke, neurology, and oncology. I started in my position a year and a half ago. At the time I started, we had the highest number of falls in the hospital, averaging around 3 per month. I understood that despite efforts and attention to fall prevention, patients do fall. It is estimated that between 700,000 to 1,000,000 people fall annually in the U.S. (Preventing Patient Falls 1 Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project, 2016). I just wanted to have an understanding of what was happening and see if there was a way to reduce our falls, at least the preventable ones.

Addressing falls is important for patient safety and quality of care. By using the Plan-Do-Study-Act (PDSA) model, I was able to get a better understanding. We were able to engage a multidisciplinary team of champions who shared an interest in helping to reduce falls. By engaging this team of nurses, nursing assistants, physical therapists, and nursing leaders, we were able to develop a culture of safety and assure all staff were aware of the fall risks and prevention interventions. We started by conducting a thorough assessment of the current rates, our current tools that identify high-risk patients, and the interventions that were used when patients were identified. We also collected data on the causes of falls to identify patterns and areas for improvement (The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities | Agency for Healthcare Research & Quality, 2017).

We use the John Hopkins Falls Risk Assessment Tool (JHFRAT), which is an evidence-based fall safety tool (Models and Tools, n.d.). When auditing, we found excellent compliance and accuracy in the use of the assessment. What we did find, was that better education and training was needed for the nursing assistants who were never really educated on how the high-risk patients would be communicated to them and the associated interventions that corresponded, such as identifying colors of non-slip footwear, chair and bed alarms, and environmental modifications (Spoon et al., 2024). We developed a colored magnet system outside the doors of the patients’ rooms so that everyone was aware before entering. We monitored compliance daily using checklists of the corresponding interventions and gave feedback regularly to the staff of our compliance. By using the PDSA model we were able to refine our process and develop a safer culture. As of today, we are on target to reduce falls by over twenty percent.

Models and Tools. (n.d.). Www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/institute-nursing/models-tools

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Preventing Patient Falls 1 Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project. (2016). https://www.aha.org/system/files/2018-01/preventing-patient-falls.pdf

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Spoon, D., de Legé, T., Oudshoorn, C., van Dijk, M., & Ista, E. (2024). Implementation strategies of fall prevention interventions in hospitals: a systematic review. BMJ Open Quality, 13(4), e003006. https://doi.org/10.1136/bmjoq-2024-003006

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The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities | Agency for Healthcare Research & Quality. (2017). Ahrq.gov. https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx.html