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Abstract
Problem: A quality improvement (QI) team within a large nonprofit medical system identified a critical lack of uniformity in fall protocols across its 13 hospitals, affecting fall pattern analysis and resource allocation. The pilot hospital, exemplifying this issue, reported the system's second-highest fall rate in fiscal year 2022, with 439 falls, including numerous injuries and fatalities. Purpose: This QI project aimed to standardize post-fall huddles and documentation across inpatient units, with the goal of reducing fall recurrence and lowering both the total number and severity of falls by effectively analyzing causes and targeting prevention strategies at both the micro (individual) and macro (system-wide) levels. Methods: Implementation included educating the nursing staff about post-fall huddles, integrating the post-fall form into the hospital's intranet, and incorporating it into the fall management policy to proactively monitor data and implement changes. The huddles focused on identifying falls’ root causes and preventive strategies against them. Results: Comparing the fall rate during the intervention period against the same 15-week period in 2022, the initiative led to a 37% reduction in total falls (from 94 to 59) and a 59% decrease in injurious falls (from 32 to 15), surpassing the 5% target. During the implementation period, there was only one repeat fall among the 59 fall incidents, highlighting the initiative's effectiveness in prevention. Despite challenges with staff adherence initially (especially in weeks two and three) and later (with week 13 at 14% compliance), the median post-fall huddle adherence rate consistently remained at 100%. Conclusions: The standardized post-fall huddle protocol significantly reduced patient falls in the pilot hospital, surpassing initial goals and demonstrating that structured approaches can markedly enhance patient safety and care quality. Continued adherence is essential for maintaining these improvements.Identifier to cite or link to this item
http://hdl.handle.net/10713/22796Collections
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