The document outlines a quality improvement initiative at Sun Coast Regional Hospital to reduce their inpatient fall rate of 50% per 1,000 patients annually. The team aims to reduce the rate by 90% through interventions targeting materials (patient/staff education), physical environment (facility design), and workforce (increasing staffing). They conduct a fishbone analysis, implement interventions using the PDSA model, measure quarterly results, and continue refining interventions such as enforcing footwear/wristband rules and routine physiotherapy checks.

1. Fall
Prevention
Fareen Ahmed
Chris Chien
Zaira Masood
Mary Randolph
Tiani Tuiolosega

2. Definition of
a Fall
• An incident that results in a person coming to rest inadvertently on
the ground or floor or other lower level.
• Patient falls, defined as the rate at which patients fall during their
hospital stays per 1,000 patient days, are a nursing-sensitive quality
indicator in the delivery of inpatient services.
• Patient fall rates are perceived as the indicator that could be most
improved through nurse-led safety strategies or interventions.
• In other words, nurses assume the primary responsibility and are
somewhat liable when a patient falls in the inpatient care unit.

3. Background
• According to reports published by the Centers for
Disease Control and Prevention Injury Center
(2007), patient falls are the:
• Third most common cause of unintentional injury
death across all age groups.
• First leading cause among people 65 years and older.

4. Facility Information
• Sun Coast Regional Hospital is a 500 bed, full service,
acute care facility with a medical staff of approximately
1,100 and employee base of 1,500.

5. Problem
• Number of Patient Falls / Number of Patient
Days x 1,000 = Fall Rate per 1,000 patients.
• Currently, the risk of inpatient falls is 50% per
1,000 patients annually.

6. Aim
• We are a quality improvement team which has been
brought in by Sun Coast Regional Hospital to help reduce
the risk of inpatient falls within their facility.
• Our goal is to reduce the risk by 90%, resulting in 10%
risk of inpatient falls per 1,000 patients annually.

7. Describing the
Intervention

8. Patients to be
Targeted for this
Initiative
• All patients aged 65 and over.
• Younger patients at increased risk of falling, such
as those with:
• History of falls
• Neurological conditions
• Cognitive problems
• Visual impairment

9. Fishbone Analysis

10. Fall Prevention
Interventions
• 1) Screening or assessment of all older patients for risk of falling.
• 2) Education and discussion of fall-prevention risks and strategies
with all staff, older patients, and their caregivers.
• 3) Recording fall-prevention education of staff, older patients, and
their caregivers.
• 4) Establishing a person’s mobility status and ensuring that they can
mobilize safely. This can be done by several criteria.
• 5) Encouraging participants in functional activities and exercise
programs.

11. Fall Prevention
Interventions
• 6) Instructing older patients on how to use their medications safely when they are
being discharged or transferred between departments/facilities.
• 7) Making the environment safe by ensuring several things.
• 8) Orientating the patient to the bed area, room, ward/unit facilities and how they
can obtain assistance.
• 9) Instructing and ensuring that older patients understand how to use care aids
prior to them being prescribed.
• 10) Having a policy in place to increase the use of restraints and bedside rails.
• 11) Consider vitamin D supplementation with calcium as a routine management
strategy.

12. Facility
Design
• A hospital can be a
dangerous and erratic
place for inpatients
because:
• Unfamiliar physical
environment (different from
that of their home setting).
• Changes in patients'
medical conditions as
related to their physical and
psychological health and
sensory systems (e.g., pain).

13. Facility
Design
• A better physical facility design may lead to better health
care outcomes, such as fewer patient falls in acute care
hospitals.
• A patient-centered facility design should promote patient safety.
• A safety-driven design with a goal to prevent inpatient fall
related injuries should be a hospital design principle.

14. Workforce
• Increase patient to
provider ratio.
• Adding
information
regarding falls onto
patients’ charts.

15. Educating Patients
& Staff
Patients
• Educate about how falls can
impact health.
• How and where to get
assistance when being
mobile.
• Steps to prevent falls as a
patient.
• Educate and train in the use
of various mobility aids.
Staff
• Educate about how falls can
impact health of patients.
• How to assess patients’ risk
regarding various
diagnoses.
• Steps to prevent patient
falls.
• Steps to take when patients
do fall.

16. • Find an opportunity to improve
• Organize a team
• Clarify current understanding of
process
• Understanding the causes
• Select an intervention(s)
FOCUS

17. Find an Opportunity
to Improve
• Sun Coast Regional Hospital is faced with a large risk of
patients falling in the facility each year. Currently, the fall
rate is 50% per 1,000 patients annually.
• Falls can be devastating, especially for seniors. Fall-
related injuries may ensue and cause further negative
health outcomes.
• As the QI team, our plan is to reduce this number
significantly by incorporating strategies that will help
reduce the risk of patients falling.

18. Organize a
• The QI team will consist of:
• Team Leader: Oversees QI process and directs the team.
• Nursing Staff: Assesses patients’ risk of falling, supervise and
assist them with their mobility needs.
• Data Technician: Records and updates information and
continuously ensures team and patients are up-to-date with
intervention strategies.
• Facilities Manager: Oversees improvement of hospital design for
patient safety and facility maintenance.
• Compliance Officer: Ensures the team is complying within safe
practices for patients when implementing interventions.

19. Clarify current
Understanding
• The current process at Sun Coast is very poor and is often
a reactive step which only takes place once patients have
already suffered from a fall.
• Falls are recorded and any fall-related injuries are then
treated promptly.
• There are minimal preventative practices and procedures
along with an insufficient amount of patient to provider
ratio.
• With such a poor process, the number of falls will
continue to increase and no improvements will be made.

20. Understanding the
Causes
• There are multiple causes that may trigger patients to fall
during their stay in the hospital, and without proper
oversight and preventative practices, falls will likely
occur often.
• As the quality improvement team, we have identified
three (3) sources that contribute highly to the annual fall
rate and which we shall address with interventions.
• Materials (education of patients & staff)
• Physical environment (facility design)
• Workforce (staff increase)

21. Selecting the
Intervention(s)
Materials
• Education and discussion of fall-prevention risks and strategies with
all staff, patients, and their caregivers.
Physical Environment
• Making the environment safe by ensuring several things (i.e., install
more hand rails, clean and hazard-free floors, well-lit rooms, etc.).
Workforce
• Orientating the patient to the bed area, room, or ward/unit facilities
and how they can obtain assistance.

22. PDSA Cycle

23. PDSA

24. Measuremen
t
• Quarterly auditing of the implementation process.
• Formula used:
• The percentage of patients who received all fall prevention
interventions can be calculated by:
• Number of patients observed having ALL appropriate
fall prevention strategies in place / Number of patients at
risk reviewed x 100% = % Results.

25. Auditing Fall Prevention

26. Auditing Fall
Prevention

27. Results
• First quarter assessment: reduction of inpatient falls by
40%
• Derived from formula: 200 / 500 x 100 = 40% of patients received
all falls prevention interventions.
• Second quarter assessment: reduction of inpatient falls
by 50%
• Third quarter assessment: reduction of inpatient falls
by 70%
• Fourth quarter assessment: reduction of inpatient falls
by 90%

28. Outcomes
• Notice less improvement between first and
second quarter assessments.
• This was due to:
• Patients not wearing proper footwear.
• Patients not wearing blue wristbands.
• Patients not seeing a physiotherapist for check-ups.

29. Solution
Implementation
• Enforce stricter rules regarding use of footwear
and blue wristbands – check patients daily to
make sure they have it on.
• Schedule monthly routine check-ups with a
physiotherapist for patients.

30. Risk Assessment
• Failure Mode and Effects Analysis (FMEA)
• Proactive risk assessment
• Prevents an adverse event
• Close examination of a process
• To help determine where improvements are needed
• Reduces likelihood of adverse affects
• Process in terms of:
• What could go wrong?
• If something does go wrong, what will be the result?
• What needs to be done to prevent a bad outcome when something
does go wrong?
• Hospitals and nursing facilities that are accredited by The Joint
Commission are required to periodically conduct a prospective
risk assessment for patient safety improvement.

31. Process
• Narrowed focus to three (3) main areas:
• Materials:
• Education for patients about falls
• Education for employees
• Physical environment:
• Keeping the beds low under a certain degree
• Open floor plan in bedrooms
• Workforce:
• Patient to provider ratio
• Adding information to charts regarding falls
• Annually conduct risk assessment with every department:
• Set goals:
• Current: Reduction of 90%
• Ultimate: No falls
• Audit charts

32. Department: Department lead:
Date: Goal:
Audit descrption:
Step Potential Failure Effect
Frequency
Severity
Detection
Criticality
Score
1
Provide staff with
education about
falls prevention
2
Staff meets with
patient before and
extended stay and
provide education
3
Staff will use new
chart formation to
indicate that the
proper education
was provided
4
Charge nurses will
work with QA and
secret shoppers to
perform audits on
charts
5
Random ized
audits will
takeplace befor
patients departure
to see if patients
felt the received
adequate
knowledge about
falls and
prevention
2012: Risk Assessment Preventing Patient Falls
No patient falls
Looking at all patient charts to ensure that patients are being provided with the proper
education about patient falls and prevention. Each chart should have a signature by an
attending nurse of physician in the chart that indicates that they did discuss fall
prevention with patients, paying special attention to higher risk patients
Risk
Assess
ment
Templat
e

33. Audit Tool:
Questionnaire

34. Audit Tool:
Diagram

35. Conclusion
• Sun Coast RH faces a high risk of patient fall rate of 50% per 1,000
patients annually.
• The QI team aims to reduce the risk by 90%.
• Conduct a fishbone analysis to find multiple causes and settled on
three (3) that were of great significance.
• Completed the FOCUS-PDSA model.
• Conduct a risk assessment of patients.
• Measured results using a formula and obtained outcomes of the
interventions.
• Reinforce interventions for patient falls and continued with QI
process.