Implementing the Fall TIPS Tool in a Medical-Surgical Unit

Abstract

Problem: Despite adopting a standard fall prevention program in conjunction with frequent patient rounding, falls consistently remained a patient safety issue in a medical-surgical unit of a non-profit community hospital. In addition, a lack of patient awareness about the fall prevention plan contributed to the fall rate of 2.2 falls per 1,000 bed days in 2020. Furthermore, in July 2021, six unintentional patient falls in this unit scored the highest number of falls in the whole hospital. Purpose: This quality improvement project aimed to implement and evaluate the effectiveness of an evidence-based bedside Fall TIPS (Tailoring Interventions for Patient Safety) tool in promoting patient and family engagement in the fall prevention plan to reduce incidents of falls. Methods: The QI project involved training nursing staff on the 3-steps fall prevention process, including performing a fall risk assessment, creating a tailored fall prevention plan, and performing the plan consistently. Staff education compliance was confirmed through a sign-off education completion form. The Fall TIPS laminated posters were placed in each patient's room. Nurses' adherence to the Fall TIPS tool was measured weekly over the 15 weeks using validated questions with Yes/No/Not-Applicable responses using a pencil/paper. Results: The result indicated that 100% of the unit RN completed the Fall TIPS training. The average Fall TIPS utilization was 63.4%. The average patients and families that verbalized patients’ fall risk factors increased to 60.5%, the baseline was 28%, and the average understanding of the fall prevention plan increased to 60.7% from the baseline of 38%. Patients’ unintentional falls decreased from 6 in July to 2 in December 2021. Conclusion: Nurses increased Fall TIPS adherence increased patient engagement in their fall prevention plan and reduced patients' fall. Additional time will be required to determine whether the practice change and outcomes are sustainable.