• Implementation of a Fall Prevention Toolkit on a Medical Surgical Unit

      Khandagale, Usha; Windemuth, Brenda (2021-05)
      Problem: In-hospital falls result in patient harm which includes minor injury, psychological distress and anxiety, and serious injuries like fractures, head trauma, and even death. The Joint Commission consistently ranks falls with serious injury as one of the top sentinel events. An acute care medical surgical unit in a community-based hospital experienced an increase in the number of falls with an overall fall rate higher than that of peer units. Purpose: The purpose of this Quality Improvement (QI) project was to implement and evaluate the benefits of, and staff adherence to, the use of Fall TIPS (Tailoring Intervention for Patient Safety) toolkit to reduce falls on a medical surgical unit. Methods: The Fall TIPS toolkit was designed to decrease the patient fall rate in hospitals and engage patients and their families in a 3-step fall prevention process including performing a fall risk assessment, creating a tailored fall prevention plan, and executing the plan regularly. Implementation of a Fall TIPS toolkit with auditing transpired weekly over 10 weeks on a medical surgical unit. Nurses’ adherence to the Fall TIPS protocol was measured weekly during implementation. Results: The results indicated that nurses’ adherence to use of the Fall TIPS toolkit averaged 78%. The run chart analysis of nurses’ adherence did not show any shifts or astronomical datapoints, and the number of runs was consistent with random variation. However, there was a 6-point upward trend in the data during weeks 2 to 7, indicating a special cause. Fall rates during the first two months of implementation were 3.39 and 2.41 per 1000 patient-days respectively, and dropped to zero during the third month. Conclusion: Nurses’ adherence to a Fall TIPS toolkit was demonstrated on a medical surgical unit, which likely resulted in a decreased patient fall rate during the final month of the project. Additional time will be needed to determine if the practice changes and outcomes are sustainable.
    • Implementation of Fall TIPS (tailoring Intervention for Patient Safety) to Reduce Patient Fall Rate

      Thang, Kathy; Bennet, DeNiece (2022-05)
      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.
    • Reducing Falls Utilizing a Fall Prevention Toolkit, Tailored Interventions for Patient Safety

      Morales, Flor M.; Gourley, Bridgitte (2021-05)
      Problem: Despite the use of numerous evidence-based interventions, in 2019, a medical surgical unit at a community hospital had a higher fall rate than its peers. The average fall and fall with injury rates were 2.6 and 1.17 per 1,000 patient days. Purpose: To implement and evaluate the effectiveness of the Tailored Interventions for Patient Safety (TIPS) fall prevention toolkit (FPTK) in an inpatient medical-surgical unit. Methods: The intervention is a three-step evidence-based tool which provided individualized universal fall precautions. Nurses completed a fall risk assessment on every admission and transfer to the floor. Then, they completed a falls poster at the bedside with the patient, educating them on their individualized fall risks and fall prevention interventions. The poster was hung at the door as a reminder tool for staff and patients. Data collected during the project included staff education, poster completion audits, and the organizations reported monthly fall rates. The data was analyzed using run charts and bar graphs. Reminders, morning huddles, and staff education were used to promote compliance. Results: Nurses and patient care technicians (100%) were all educated prior to intervention implementation. The average compliance rate of completed TIPS posters was 67%. The fall rate increased during the intervention phase by 18% compared to the pre-interventions phase. There were no changes in fall with injury rates post intervention when compared to pre-intervention. Despite an increase in falls during the implementation phase, there was a positive trend that showed that as compliance rates increased from October to December, fall rates decreased. Conclusions: The compliance rate was not met and fall rates were higher post-intervention. Additional reminders, weekly huddles, and meetings could be held to re-educate staff and allow for discussion of barriers and facilitators. October and November’s low rate of poster completion may correlate with the higher fall rates. In December, there were less falls and compliance rates were higher. Strategies and tactics should be utilized in order to increase intervention compliance, increase sustainability, and decrease fall and fall with injury rates in the future. Limitations included a COVID pandemic and forgetfulness in completing the poster.
    • Reducing Falls with Tailored Intervention for Patient Safety on a Neuro Unit

      Lockard, Darlene; Gourley, Bridgitte (2021-05)
      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.