Advocate Lutheran General Hospital

Presentation Notes

Poster presented at: Building Bridges to Nursing Research; April 14, 2023; Milwaukee, WI.


Background or Significance: Through evidence based research an audit to identify the reasons for falls was initiated. The top six indications were (1) sedative medications (2) Connection to an IV, (3) impulsive behavior (4) previous falls (5) mobility, vision or balance issues (6) sudden change in condition. This six point assessment lead to identifying and tracking high fall risk patients, as well as utilizing appropriate safety measures.

Purpose of the project or study: In response to a high fall rate on a General Medicine Unit, two bedside nurses, both members of the High Reliability Unit (HRU) team, implemented an innovative program that eliminated falls on the unit during a 6-month observation period. Literature review Advocate Healthcare protocols, Morse Fall Scale, Current Care Plans, and Safety Event Reports Description of Sample or Population The project was carried out as a pilot on a General Medicine Unit for 6 months. The type of patients on this unit was wide spread in acuity and age. Setting Acute Medical Surgical Hospital setting. 29 bed unit.

Results or Outcomes: Pre-implementation data showed a rolling falls rate of 3.8 falls per patient day from January 2022 to June 2022. Post implementation rolling data shows a fall rate of 0.0 from July 2022 to November 2022.

Conclusions and Implications: Education on the rationale behind, and use of the protocol was delivered during unit practice council meetings and shift huddles. Team members were instructed to perform and document a fall assessment every 12 hours for each patient. Assessment cards utilized written descriptions as well as images to meet various learner types. Each nurse reported risk assessment scores to the charge nurse who kept a unit wide fall risk log to help with unit awareness and implementation of safety measures.

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