Implementation of Fall TIPS (tailoring Intervention for Patient Safety) to Reduce Patient Fall Rate
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Abstract
Problem: Inpatient falls are the most common safety event that negatively impacts both patients and the healthcare systems. In a suburban community hospital, the progressive care unit (PCU) experienced a 25% higher fall rate in 2020 than all other units in the hospital combined despite comprehensive fall prevention protocols. Therefore, a quality improvement (QI) project was implemented on this floor and on the Immediate Care Unit (IMCU). Purpose: This QI project aimed to implement a bedside Fall TIPS poster to communicate patientspecific risk factors to the multidisciplinary teams and use a tailored fall prevention plan based on their fall risks while engaging patients and their families to reduce fall rates. Methods: This project was implemented over 13-weeks during the fall of 2021. Clinical nurses on PCU and IMCU were educated on the bedside Fall TIPS posters with their patients and family members. Clinical nurses went over the bedside Fall TIPS poster at admission and every shift with their patients and families. The poster was placed on the wall next to the whiteboard as a reminder for the patient and a visual aid for the multidisciplinary team involved in the patient’s care. All patients admitted to the units between September 2021 and mid- December 2021, were included. All clinical nurses on both units completed a competency checklist before implementation. Data on the Fall TIPS poster use was collected using an audit tool created by the project leader. Unit fall rate data was collected through the hospital incident reporting system. Results: 100 % of clinical nurses were educated on the use of the Fall TIPS. Based on weekly audits, approximately 20-80% of the nurses adhered to the use of the Fall TIPS poster. There was a total of 4 falls on PCU and one fall on IMCU. Conclusion: Bedside Fall TIPS poster helped patients, families, and the care team understand the patient’s fall risk and interventions.