Fall Prevention
Lydia Burgess, Ellie Sullivan, Riley Mackay, Julia Curtin, Michael Dew
Bon Secours Memorial College of Nursing
Abstract Data and Analysis of the Issue
CVSU: Cardiovascular Services Unit
Description of Issue: Hospital falls increase the risk of inpatient injuries and
Patient Population: all patients on this unit have a cardiac
length of stay for patients. Saint Mary’s Hospital wishes to reduce the fall
issues/diagnoses (heart failure, surgical, NSTEMI/STEMI, blood pressure,
rates on the Cardiovascular Services Unit. The purpose of this project is to see
EKG abnormalities)
how implementing a fall safety champion on the unit can reduce the number
Beds on unit: 20 beds total
of falls.
Patients that are deemed a high fall risk are >50 on the Predictive Assessment
Data Analysis: The data was collected through nursing staff surveys, review
(PA) Fall Risk Score.
of fall audits, and on the unit observations.
PA Fall Risk Score takes into account patient diagnoses, medications,
history, vitals, anything that would put the patient at risk for falling and
Root Cause: Fall preventatives (signage, bed/chair alarms,etc.) were not
automatically generates a score 0-100.
implemented to all patients on the unit.
Proposed solution: We propose to identify a nurse (on each shift - day and
night) to be the fall safety champion, who will be responsible for ensuring all
fall preventatives are in place and appropriately documented. Also, we
propose to use all fall preventative measures on all 20 patients on the unit.
Conclusion: Fall safety champions and use of fall preventative measures on
all patients will reduce the total rate of falls.
Site visit: 2/14/24
The unit’s main fall preventative measures are: yellow “fall risk” identifiable
armband, in room Schmid board being up to date, functioning bed/chair alarm
(3 measurable preventions). CVSU staff implements a “Stay with Me”
protocol for every patient that is a high fall risk to avoid falls going to and
from the bathroom, bed to chair, etc.
Introduction and Description of ➔ 12 patients were >50 on the PA Fall Risk Score = 60% of unit high fall
risk
➔ 25% of patients were missing 1 of 3 measurable fall preventions
the Issue ➔ 8% of patients were missing 2 of 3 measurable fall preventions
➔ 33% of patients were missing 3 of 3 measurable fall preventions
➔ 8% of patients had a live video monitor which is the highest level of fall
Macro Level: “Each year, roughly 700,000 to 1 million patient falls occur in prevention
U.S. hospitals resulting in around 250,000 injuries and up to 11,000 deaths.6
➔ Only 25% of patients had all 3 measurable fall preventions in place
About 2% of hospitalized patients fall at least once during their stay.7,8
Approximately one in four falls result in injury, with about 10% resulting in
serious injury.9” (LeLaurin and Shorr).
Survey Data:
➔ Easier to comply to fall prevention measures if staff put a bed/chair alarm
Micro Level: In 2023, the unit incurred 10 falls with no two consecutive on all 20 patients in the unit at all times.
months of more than 2 falls. In 2024, there have been 4 falls (2 in Jan, 2 in ➔ Patient ambulation time or “chair time” is sacrificed because of a high fall
Feb). These falls are an ongoing issue because falls can lead to an increase risk score.
risk of injury and prolong patient’s length of stay. All participants stated that a fall safety champion for each shift (day and night
shift) would be helpful to hold accountability for each patient and that it does
not fall on one individual staff member.
Root Cause
Root Cause: All fall preventative measures were not consistently in place,
additionally there is not a safety champion for either shift.
Rationale: Patients lack an understanding of their higher risk for falls due to
their diagnoses that symptoms can include weakness, shortness of breath,
orthostatic hypotension, and fatigue (Preventing and Managing Falls in
Adults with Cardiovascular Disease, n.d.). Patients’ lack of education lead to
patient refusal or newer staff not implementing all fall preventative measures
for high fall risk patients.
Proposed
AIM Solution
- Proposed Solution Conclusion
Hypothesis: If all three fall preventative measures are in place and a fall
safety champion is present for each shift, then fall prevalence will decrease. The Issue: The Cardiovascular Services Unit at St Mary’s Hospital wants to
decrease their fall rates due to the result of increased injuries and prolonged
We want to increase the utilization of fall preventative measures and hospital admissions.
propose the implementation of a fall safety champion on St. Mary’s
Cardiovascular Services Unit to therefore decrease fall percentages by Data Analysis: We collected data by using the unit falls census for 2023 and
50% by August 1st, 2024. 2024 year to date, one site visit February 14th 2024, and a online survey that
had unit staff participants.
Root Cause: The identified root cause of increased falls on CVSU is that all
fall preventative measures were not consistently in place and that there is not
Logistics: a safety champion assigned for either day or night shift.
● Delegation of fall champion to personnel per shift
● having and completing fall prevention checklist every shift to Proposed Solution: We think that utilizing all fall preventative measures for
ensure measures are in place all patients and implementing a fall safety champion will decrease fall
percentages by 50% on the unit of CVSU.
“Fall prevention is important in any health care setting as a means of
Stakeholders: improving patient safety” (Szumlas, S., Groszek, J., Kitt, S., Payson, C.,
● Patients & Stack, K., 2004).
● Nurses
● Assistive Personnel
● Hospital Administration
● Health Systems
References
Potential costs:
● We suggest incentivising the duty of safety champion by placing a LeLaurin, Jennifer H., and Ronald I. Shorr. “Preventing Falls in Hospitalized
$1-$2 hourly incentive for whoever takes the responsibility per
shift ($12-$24 per 12 hour shift) Patients.” Clinics in Geriatric Medicine, vol. 35, no. 2, 1 Mar. 2019, pp.
● Buying adequate plug in bed alarms for beds that are not equipped
from factory. These are reusable so they would be an infrequent
cost. ($30-$50 per alarm, without wholesale pricing) 273–283, www.ncbi.nlm.nih.gov/pmc/articles/PMC6446937/,
● Paper and ink costs associated with extra checklists and fall signs
https://doi.org/10.1016/j.cger.2019.01.00
posted (4-9 cents per printed checklist)
Preventing and Managing Falls in Adults with Cardiovascular Disease. (n.d.).
Timeline: American Heart Association.
● implement a way for safety champion to be chosen for every shift
(whether it be rotating or the same few people each time etc.) by https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardi
May 1st 2024
● Start the program by May 15th 2024 ovascular-disease/preventing-and-managing-falls#:~:text=Cardiovascular
● Evaluate efficacy on August 1st, 2024 (giving 2.5 months of trial)
to see if falls have decreased
%20conditions
Szumlas, S., Groszek, J., Kitt, S., Payson, C., & Stack, K. (2004). Take a
Data Collection:
● Compare fall rates monthly (with each other and
second glance: A novel approach to inpatient fall prevention. The Joint
pre-implementation months for the last year) Commission Journal on Quality and Safety, 30(6), 295-302.
● make an online survey for floor nurses to take that gives feedback
in order to potentially revise program to better suit needs and
improve efficacy