Reducing

Patient Falls
on the
Telemetry Unit
Korri Tanner, Sydney Carskadon,
Claire Caviolo, Chance Sasser
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St. Mary’s Hospital
Telemetry Unit
Tucson, Az
● Telemetry Unit
● Staffed 24/7
○ RNs: 4-5 patient ratio
○ PCTs: 10-15 patient ratio
○ Unit Clerk
○ Providers (MD, NP, PA)
● Adults in stable condition who have a
history of heart complications
● ~ 65 patient/day
● Stable leadership team structure

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 QUALITY IMPROVEMENT
ISSUE
Number of Falls for Telemetry Patients
● Causes:
○ Altered Mental Status
○ Physical Environment
○ Understaffed
● Potential Consequences:
○ Increased morbidity/mortality
○ Increased hospital LOS
○ Increased staff injuries
● Current Prevention Methods:
○ Non-slip footwear
○ Fall Risk wristbands
○ Bed alarms

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MODEL FOR IMPROVEMENT:

FORMING THE
TEAM

● Nurse Manager
● Charge Nurse
● Nurse Educator
● RNs, PCTs, PT/OT

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 MODEL FOR IMPROVEMENT:

SETTING AIMS

Our AIM: Reduce the

number of falls for
telemetry patients by 50%
within one month of
implementation.

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 MODEL FOR IMPROVEMENT:

ESTABLISHING MEASURES
● Outcome Measure:
○ Number of falls on telemetry unit
● Current Unit Data:
○ Last 4 Months = 29 Falls
● National Average: 3-5 falls per 1000
bed-days (Patient Safety Network, 2019).

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 MODEL FOR IMPROVEMENT:
SELECTING CHANGES

1 2 3
Incorporate Continuity of
Establish Safe Precautions in Care Among
Environment Care Plan Staff
● Call lights within ● Hourly rounding ● Consistent fall risk
reach at all times ● Consistent and/or assessment
● Room signage scheduled ● Consistent patient
toileting education regarding
fall risk
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TESTING CHANGES
PLAN

Vestibulum congue
Objective:
● Decrease number of
falls on the telemetry
ACT DO
unit by implementing
hourly rounding on High
Fall Risk patients. STUDY
(Gliner et al., 2021)
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TESTING CHANGES
(CONT.) PLAN
Plan:

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● 1 week planning period
● 1 week of staff education:
○ Email
ACT DO
○ Pamphlet in break room
○ Discussion during pre-shift
huddle
○ Bimonthly Fall Risk
STUDY
Computer-Based Trainings
(Gliner et al., 2021)
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TESTING CHANGES
(CONT.) PLAN

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Predictions:
● Immediate reduction in number of
falls ACT DO
● Potential for delay of care

STUDY
(Gliner et al., 2021)
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TESTING CHANGES
(CONT.) PLAN
Implementation Day:

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● Hourly rounding on High Fall Risk
patients on the unit completed by
assigned RN within the 12 hour ACT DO
shift.
Tracking:
● Conduct daily fall audits
● Compare daily data at the end of
each week
STUDY
● Tracking patient fall risk
(Gliner et al., 2021) 11
assessments in EMR
TESTING CHANGES
(CONT.) PLAN
Evaluate Daily:

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● Number of Falls
●
●
Cause of Falls
Fall Prevention Measures in Place ACT DO
Next Steps:
● Continue fall daily audits until 50%
reduction occurs.
● Return to 5 audits per week at that STUDY
point.
(Gliner et al., 2021)
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POTENTIAL BARRIERS
TO IMPLEMENTATION
Leadership:
● Ineffective communication
● Plan: SBAR used during pre-shift huddle
(Jeong & Kim, 2020)
Staff:
● Lack of cooperation between RNs and
PCTs
● Insufficient involvement from unit staff
● Plan: Incentives for completing
trainings, encourage proper delegation
to prevent delay of care
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VISUAL AIDE

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 REFERENCES
Jeong, J. H., & Kim, E. J. (2020). Development and evaluation of an SBAR-based fall simulation program for nursing students. Asian

Nursing Research, 14(2), 114–121. https://doi.org/10.1016/j.anr.2020.04.004

Patient Safety Network. (2019). Falls. Agency for Healthcare Research and Quality.

https://psnet.ahrq.gov/primer/falls#:~:text=Falls%20are%20a%20common%20and,hospitalized%20patients%20fall%20each%2

0year.

Gliner, M., Dorris, J., Aiyelawo, K., Morris, E., Hurdle-Rabb, D., & Frazier, C. (2021). Patient falls, nurse communication, and nurse

hourly rounding in acute care: Linking patient experience and outcomes. Journal of Public Health Management and Practice,

28(2). https://doi.org/10.1097/phh.0000000000001387

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