Preventing Falls in the Surgical Setting by Implementing a Fall Prevention Bundle

Abstract

Problem & Purpose: Perioperative adult patients are at a high risk of falls due to gait and balance disturbances, postoperative polypharmacy, intravascular volume status changes, and unfamiliarity with the perioperative environment. There were eight preventable falls during 2020 in outpatient adult perioperative patients at an urban hospital despite current fall prevention strategies. The purpose of this quality improvement project was to evaluate a fall prevention bundle, which included a fall safety agreement, patient falls education, and the Fall Tailoring Interventions for Patient Safety tool (Fall T.I.P.S.). Methods: This quality improvement project was implemented in three surgical units over 16 weeks from August to December 2021. Ninety-one registered nurses, 14 patient care technicians, six transporters, nine patient service representatives, and two administrative assistants were trained on the fall prevention bundle. The preop nurse gave all adult surgical patients the fall safety agreement to review and sign. The preop nurse implemented the Fall T.I.P.S. tool if the adult surgical patient has a Morse Fall Scale (MFS) score >51. Results: Weekly data were collected from August 30, 2021 to December 23, 2021, including registered nurse adherence to implementing and documenting interventions, and fall rates. By the end of the project, the average percentage of staff adherence with documentation of interventions was 80.8%. The average percentage of patients who received education and signed the fall safety agreement was 92%. The implementation rate of the Fall T.I.P.S. tool for patients with a MFS >51 was an average of 67.1%. The average number of patients with MFS >51 was 3.62 patients per day, which could have caused a high variability in the Fall T.I.P.S. tool implementation rate making the results less meaningful and unreliable. During project implementation, there were no falls reported. Conclusions: The fall safety agreement provides standardized fall education for patients and their families and can be modified to fit practically any setting. It was also found that the fall safety agreement was well received by patients and their families. The Fall T.I.P.S. tool is an effective communication tool used to quickly notify staff of a patient’s risk of falling and individualized interventions.