Reducing Falls with Tailored Intervention for Patient Safety on a Neuro Unit

Abstract

Problem & Purpose: Falls on the neuro care unit at a suburban hospital in 2019 averaged 2.4 falls per month. This unit has the second highest fall rate at the medical center. Compared to the National Database of Nursing Quality Indicators for total falls in 2019, the neuro care unit was higher than the benchmark and averaged 2.98 falls per 1000 patient days with the benchmark at 2.95 falls per 1000 patient days. The purpose of this quality improvement project is to implement and evaluate the effectiveness of a Tailored Intervention for Patient Safety toolkit to reduce falls on an adult inpatient neuro care unit. The Tailored Intervention for Patient Safety is a 3 step fall prevention process that includes Universal Fall Precautions that apply to all patients admitted or transferred to the neuro care unit. Methods: Methods employed for assessing completeness and accuracy of data were done by spot checking audits twice weekly to make sure Tailored Intervention for Patient Safety poster at bedside and handout in admissions folders were properly filled out. This data was analyzed and graphed in a run chart to analyze for trends by looking for runs, shifts, and alternating points that suggest cause variation exists. The hospital provided monthly falls and falls with injury was and calculated using falls per 1000 patient days. This was plotted in a bar graph to compare pre-intervention and post-intervention to ensure completeness and accuracy of the data. Results: TIPS poster compliance was 90%, with 100% of staff trained. Falls decreased by 67% compared to pre/post-intervention data from 2019 to 2020. Falls with injury decreased by 14% compared to pre/post-intervention data from 2019 to 2020. TIPS handout compliance was 0%. Conclusions: TIPS adherence reduced falls and falls with injury. This reduces hospital cost and improves patient care.