QUALITY

IMPROVEMENT FOR
FALLS AT NORTHWEST
MEDICAL CENTER
By: Nicole Pangborn, Sydney Maier, Katherine White, Emma
Kampschroeder, Jenni Kim
Project Team and Unit Introduction

• Northwest Medical Center (NWMC- main)

• Medical-surgical unit (neuro)
• Adult patients requiring acute care
• The unit has about 50 beds
• The nurse to pt ratio is 6:1 with a tech
• Individual team structure
 Quality Improvement Issue

Issue:
• Falls on the unit
 Quality Improvement Issue

Current Practices:
• Fall safety check-list (safety equipment/attire)
• Sitters/virtual monitoring
• Posting fall count
• Documenting Morse Fall Risk score
Forming the Team

Meet the stakeholders...

1. Nurse educator
2. Nurse manager
3. Bedside nurses
4. Charge nurse
5. Hospital Chief Financial
Officer/Finance Team
 Setting Aims
Aim Statement
To achieve one or less falls per month in the med-surg neuro
unit, we will educate and monitor nurses on the unit on accurate
fall risk scoring to ensure proper interventions are implemented,
over an 8 month period.

Aims for Improvement

• Safety – reduce falls, prevent injuries
• Effective – equipped with knowledge to
identify patients at risk and intervene
proactively
 Establishing Measures

• Quality improvement measure - number of falls

• National Benchmark
o Med-surg unit in the US – 3.44 falls per 1000 patient days
• Unit Data
o 2024 (Jan-Mar) - 7 falls
o 2023 – 15 falls
o 2022 – 19 falls
 Selecting the Changes

Possible Chosen
Changes Change
• Bed alarms
• Nursing Education,
• Accurately completing the fall specifically educating
checklist on accurately scoring
• Nursing Education
patients as a fall risk
• Fall band and non-slip socks
• Communicating with the team
 Testing Changes: PLAN
● Objectives:
○ To decrease the number of falls on the unit to 1 or less per month until
the end of the year
○ To maintain the total number of annual falls at or under 15, the number
of falls last year
§ By implementing required education on appropriate fall risk scoring
and interventions for RNs
● Anticipated outcomes:
○ After the RN education session, there will be a maximum of 1 fall on the
unit each month.
○ By the end of the 8-month study period, the number of annual falls on
the unit will not exceed 15.
● 2-week planning period for nursing leadership to meet, develop education
protocol, and ensure adequate resource availability for fall interventions
Testing Changes
 Testing Changes
DO STUDY
Implementation
● Charge nurse will monitor completed
fall risk assessments for accuracy
over the next 8 months
● Bedside nurses will attend one 60-
minute education session on
accurate scoring and fall
interventions
● Posters around unit at month 2 and
huddle reinforcement at month 4
Data evaluation
● Data will be evaluated every 2
months until the end of the year
○ Number of falls
○ Number of accurate fall risk
scores as confirmed by nursing
leadership
○ Number of completed
fall checklists
Objective met?
 Potential Barriers to Implementation
Interdependence
• Nurses do not have a strong
relationship with new nurse
supervisor
• Intervention:
• Team-bonding experience
• When the team is bonded,
there is better
communication, and the
nurses are more likely to
follow protocol
Staff focus
• Nurse workload is too much
• Intervention:
• Delegate basic tasks such as
ADL’s to PCT’s
• With less workload comes
more time to document fall
risk for each patient
(Gerrish et al., 2019)
 Project Timeline

EDUCATION HUDDLE
CLASSES REINFORCEMENT

APR-JUN JULY-AUG SEPT-OCT NOV-DEC

SIGNS FINAL
PUT UP EVALUATION
AROUND
UNIT
 References
Gerrish, K., Keen, C., & Palfreyman, J. (2019). Learning from a clinical microsystems quality improvement initiative
to promote integrated care across a falls care pathway. Primary Health Care Research & Development, 20.
https://doi.org/10.1017/S1463423618000567

Jewell, V. D., Capistran, K., Flecky, K., Qi, Y., & Fellman, S. (2020). Prediction of falls in acute care using the Morse
Fall Risk Scale. Occupational Therapy in Health Care, 34(4), 307–319.
https://doi.org/10.1080/07380577.2020.1815928

Mitchell, D., Raymond, M., Jellett, J., Webb-St Mart, M., Boyd, L., Botti, M., Steen, K., Hutchinson, A., Redley, B., &
Haines, T. (2018). Where are falls prevention resources allocated by hospitals and what do they cost? A cross sectional
survey using semi-structured interviews of key informants at six Australian health services. International Journal of
Nursing Studies, 86, 52–59. https://doi.org/10.1016/j.ijnurstu.2018.06.002

Parreira, P., Santos-Costa, P., Neri, M., Marques, A., Queirós, P., & Salgueiro-Oliveira, A. (2021). Work methods for
nursing care delivery. International Journal of Environmental Research and Public Health, 18(4), 2088.
https://doi.org/10.3390/ijerph18042088
 THANKS!
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