Fall Reduction Program
December 2006- present

Project purpose:

The purpose of the fall reduction project is to positively impact patient safety by reducing inpatient falls and fall-related injuries, by implementing a comprehensive Fall Reduction program.

Project goals and objectives:

To consistently utilize a comprehensive inpatient fall reduction program that includes an assessment by a team of professionals with interventions that address a variety of approaches that is individualized to the patient needs.

Project scope:

The fall reduction team will focus on the following:

• Review and revise as necessary current fall reduction policy and procedure including creating a definition of falls.
• Create an understanding throughout the organization of the importance of the fall prevention program.
• Review current inpatient fall data and determine the gap.
• Create and implement an improvement plan.
• Measure results

Actions taken:

Three multidisciplinary process teams were formed. They consisted of an Assessment and Intervention Team, Communication and Education Team and a Tools Team. The teams met on a regular basis to develop the following deliverables:

• Create uniform, valid, reliable data that will be used consistently across all inpatient units.
• Measure compliance with procedure and utilization of tools (fall risk assessment tool, reassessment every shift and post-fall assessment).
• Create a process for staff to enter data electronically that will support the fall reduction program.

Evaluation and Results:

During the month of May, Nursing Staff throughout the organization will be educated on the implementation and use of the new fall assessment tool. Implementation of the new Fall Risk Reduction Plan will begin in June. The steering committee will continue to meet monthly to review data, measure results and make adjustments as needed. We will be utilizing the PDCA (plan, do, check, act) cycle to assure that the program we have implemented is successful.