Background: In the United States, patient falls have become a critical issue that negatively impacts our healthcare system. Even with continued emphasis on fall prevention, falls continue to occur frequently in hospitals across the United States. Falls are not benign events, and often lead to some level of patient harm or even death. Furthermore, since falls have been designated preventable hospital acquired conditions in acute care settings, they are no longer be reimbursed by insurance companies. The risk to patient safety as well as lack of reimbursement for falls are two major factors that support the need to prevent falls in acute care settings. In perioperative units, a highly vulnerable population exists, along with barriers to fall prevention.
Local Problem: In a community-based hospital located in a Maryland suburban community, a comprehensive fall prevention plan was initiated to promote safety and prevent falls in this population.
Interventions: Based on an extensive literature review, a fall prevention bundle was initiated on all adult patients in the perioperative units. This bundle included the following components:
high fall risk wrist bands, non-skid socks, fall prevention signs, and fall education. Bundle compliance was tracked and measured using compliance audit tools. Additionally, falls were calculated as number of patient falls per 1,000 bed days.
Results: After initiation of the comprehensive fall prevention bundle, staff had a high compliance rate with measures: wrist bands present, 97%; signs present, 100%; call bell within reach, 97%; education given, 89%; and non-skid socks on, 99%. Furthermore, no falls have occurred since bundle implementation. Therefore, the falls rate during this time is 0.
Conclusions: Based on this data, the successful implementation of a fall prevention bundle has the potential to decrease the number of falls in a vulnerable population.