Aurora St. Luke’s Medical Center

Presentation Notes

Quality Improvement poster presented at Nursing Passion: Re-Igniting the Art & Science, Advocate Aurora Health Nursing & Research Conference 2022; November 9, 2022; virtual.


Background: Falls are an adverse event and can lead to patient injury and harm. Fall prevention in the acute care healthcare setting is multi-faceted and requires a team approach. Active engagement and communication with staff are key for fall prevention programs (AHRQ, 2013).

Local problem: In 2020 on this medical surgical unit there were 22 falls.

Method: A quality improvement project lead by the unit falls champion and leadership to reduce the number of falls on the unit was conducted in November 2020. Audits were used as the primary source of information and source for action planning. Education focused on fall prevention as a unit problem, versus individual patient or staff. All staff were encouraged to answer/run to bed or chair alarms, including leadership setting the example, with recognition for their “hustle”. Additional interventions implemented to aid in fall reduction included adding the fall risk score to each team member’s list in EPIC, engagement of patients in plan of care and fall prevention, and patients at risk for falls were highlighted for all staff at the twice daily huddle. Audits were conducted three times per week for consistency with real time coaching provided by a peer who was the unit fall champion. Findings from audits and examples of were emailed out to staff for education and reinforcement.

Results/Conclusions: Staff awareness and team responsibility regarding falls increased and the culture of the unit shifted. Falls data for 2021 decreased to 12.

Implications for practice: Fall prevention is the responsibility of the healthcare team. Highlighting at risk patients during daily shift huddles, real time coaching with follow up from a peer, and fall prevention performance recognition are effective strategies for fall reduction and staff engagement.

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