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Aurora St. Luke's Medical Center

Presentation Notes

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


Background: Falls occur in approximately 700,000-1,000,000 hospital patients each year and one-third of these falls are preventable (AHRQ, 2021). Fall prevention is multi-factorial and includes addressing patients underlying health conditions as well as healthcare environment.

Local problem: In 2020, this inpatient/observation unit had one of the highest rate of falls at the site with an average of 2.45 falls per month with 27 total falls in the year 2020.

Method: The Plan Do Study Act method was used to guide this fall prevention quality improvement project. A team consisting of unit leadership, falls champions, and CNS met and developed a 30/60/90-day plan. This included a communication plan on how to implement the project, visually display falls data, and communicate updates. An initial gap analysis and observation were conducted for three weeks 1-2 times per week, to observe clinical practice, environmental factors, and identify areas for improvement. Findings from the gap analysis highlighted key focus areas of improvement. The areas were addressed with fall prevention “sprint” interventions broken down into 3 focus areas implemented biweekly. Interventions built upon the previous weeks and included: red socks, chair alarms, bed alarms, non-slip socks, patient rounding, and signage to name a few. Audits and falls data were tracked and shared across staff and leadership monthly and quarterly with milestones celebrated.

Results/Conclusions: Since the project was implemented July 28th, 2021 there was one fall and the unit had a period of 117 days without any falls from August 2nd-November 26th, 2021. Overall, falls on the unit decreased by 86% in the first 30 days of the project. Falls related to behavioral events or unanticipated/unpreventable medical conditions (i.e., cardiac or respiratory arrest) were excluded.

Implications for practice: Multi-faceted fall prevention interventions, visual awareness of data, and unit accountability can influence the number of falls that occur. Continued work with an emphasis on fall prevention, unit specific patient population and culture, and transparent communication of real time data for all staff is key.

Document Type

Oral/Podium Presentation




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