Professional Documents
Culture Documents
Katharine Koop
March 19,2018
“I Pledge”
REDUCING FALLS IN HEALTHCARE SETTINGS 2
Introduction
This quality improvement project has been performed to help with the reduction of falls
among the elderly in order to prevent injury and improve patient outcomes in a healthcare
setting. There have been numerous research studies that show falls in the elderly can cause injury
to the individual and some of the injuries can lead to poor patient outcomes including death. As a
skilled nursing facility manager, a staff nurse in long term care and the hospital setting there has
been experience gained related to falls with injury and poor patient outcomes among the elderly.
Education and employee engagement regarding hourly rounding, standard fall precautions and
the use of individualized falls precautions will be addressed in this project in order to provide
According to The Center for Disease Control (CDC) more than one third of adults 65 and
Each year, millions of people 65 and older are treated in emergency departments
because of falls.
Over 800,000 patients a year are hospitalized because of a fall injury, most often
Problem
There are currently an increased number of falls at 10-15 falls per month related to
resident’s condition and lack of staff engagement. This increased number of falls produces an
increased number of injuries related to falls. This plan to engage staff and educate them
regarding the importance of increased rounding to reduce the number of falls is imperative to
improve resident outcomes. We aim to reduce the number of falls by 50% from February 1, 2018
Causes of increased falls have been an ongoing challenge as the nurse to patient ratio
proves to continue to provide insufficient staff for hourly rounding. The trickle-down effect of
insufficient staff causes lack of compliance with standard fall precautions. It has been noted that
fall ID bands and fall risk alert signs were not used consistently.
Implementation
The leadership team provided staff education. Fall incidence was monitored and
documented daily on a monthly chart with the time of fall, whether or not the fall was witnessed,
the reason for the fall and the area of where the fall occurred. Residents with high risk for fall
have been monitored closely and leaders collaborated to create individualized fall prevention
plans. Mandatory continuing education was provided to staff and continued feedback has been
encouraged for ideas to further improve the reduction of the incidence of falls. Collaboration of
the healthcare team to improve staff awareness and engagement to encourage more frequent
rounding has been provided and will be ongoing. Residents have been encouraged to engage in
activities and family members have also be encouraged to participate when available. Staff was
encouraged to ensure fall ID bands and falls risk signs were placed at time of admission.
REDUCING FALLS IN HEALTHCARE SETTINGS 4
The use of colored hourly rounding sheets was provided in February with the intention
that nursing staff would initial every hour to ensure hourly rounding was provided. The
implementation of the above stated hourly rounding sheets was unsuccessful as staff feedback
proved to be unhappy with “extra documentation.” The hourly rounding on the electronic medical
records (EMR) tool was further encouraged and weekly chart audits was implemented.
Outcomes
documentation by 100% in March 2018. Outcomes of reduction of falls were tracked and will
continue to be utilized by using a collection of data from daily and monthly fall charts. The
outcome of reduced falls has been discussed by the leadership team daily and necessary changes
will continue to be produced in the plan as needed. Data tracking has supplied evidence of
improvements. Outcome measure tables have been provided to ensure safety measures are
successful. The number of falls was reduced by 50% by March 27, 2018 as evidenced by data
Managers accepted the use of monthly fall assessment tracking and a board was created
Barriers
Barriers included limited staff, increased residents of the geriatric population with
dementia and other comorbidities, medications that cause drowsiness and lack of staff
participation with changes. Limited staff has been a real challenge throughout the quality
References
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
Web-based Injury Statistics Query and Reporting System. Accessed March 27, 2018.