Fall Prevention Project

Lydia Burgess, Michael Dew, Ellie Sullivan, Julia Curtin, & Riley Mackay
 Macro/Micro Level
Macro:
● “Each year, roughly 700,000 to 1 million
patient falls occur in U.S. hospitals resulting in
around 250,000 injuries and up to 11,000
deaths.6 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).
Micro:
● In 2023, CVSU had 10 falls in one year,
without two consecutive months having
more than two falls.
● In 2024, CVSU has had 4 falls (2 in Jan and 2
in Feb).
● Falls lead to elongated hospital stays due to
the injuries acquired.
Data Analysis - Cardiovascular Services Unit
Patient population: 20 beds total

● All patients on this unit have cardiac issues/diagnoses (heart failure, surgical, NSTEMI/STEMI, blood pressure, EKG
abnormalities).

Predictive Assessment (PA) Fall Risk Score:

“The EHR determines patients’ fall risk scores based on documentation already in the chart, so nurses don’t need to calculate scores manually. By
introducing predictive model risk scores and removing the need for nurses to document an assessment to calculate the scores, one organization
reduced fall assessment clicks and keystrokes by 50% without increasing the rate of inpatient falls” (Carroll & Eberlein, 2023).

● Takes into account patient diagnoses, medications, history, vitals, anything that would put the patient at risk for falling and
automatically generates a score 0-100.
● Score >50 deemed high fall risk
Data Analysis

Unit’s fall preventative measures:

● Yellow “fall risk” identifiable armband,

Schmid board up to date, functioning
bed/chair alarm.
○ All three of these are “measurable”
● CVSU staff implements “Stay with Me”
protocol for every patient that is high fall
risk.
Site Visit: 2/14/24

● 12 patients were >50 PA Fall Risk Score Only 25% of patients on the unit had all 3
○ 60% of unit high fall risk measurable fall preventions in place.
● 25% of patients were missing 1 of 3 fall
preventions
● 8% of patients were missing 2 of 3 fall
preventions
● 33% of patients were missing all 3 fall
preventions
● 8% of patients had a live monitor
Survey Data

● Easier to comply to fall prevention measures if staff put a bed/chair alarm on all 20 patients in the
unit at all times.
● Patient ambulation time or “chair time” is sacrificed because of a high fall risk score.

All participants stated that a fall safety champion for each shift (day and night) would be helpful to hold
accountability for each patient so that the role does not fall on one individual staff member.
Root and Rationale
Root Cause: All fall preventative
measures were not consistently in place, ● Patients lack an understanding of their higher risk for falls
additionally there is not a safety
champion for day or night shift on CVSU.
Rationale:
due to their diagnoses that have symptoms such as
weakness, shortness of breath, orthostatic hypotension,
and fatigue (Preventing and Managing Falls in Adults with
Cardiovascular Disease, n.d.).
● Staff inconsistently educating patients on fall prevention
can lead to reduced safety awareness or noncompliance.
● Inconsistency of implementation of fall preventative
measures for high fall risk patients (bed alarms, grip socks,
fall risk armband).
Hypothesis/AIM Statement
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.
AIM Statement:
We want to increase the utilization of fall
preventative measures and propose the
implementation of a fall safety champion on
St. Mary’s Cardiovascular Services Unit to
therefore decrease fall percentages by 50% by
August 1st, 2024.
Logistics Stakeholders

● Delegating a fall/safety champion per shift ● Patients

● Having and completing fall prevention ● Nurses
checklist every shift to ensure measures are ● Assistive Personnel
in place ● Hospital Administration
● Health Systems
 Potential Costs
● We suggest incentivising the duty of safety champion by placing a $1-$2 hourly
incentive for whoever takes the responsibility per shift ($12-$24 per 12 hour shift)
● Buying adequate plug in bed alarms for beds that are not equipped from factory.
These are reusable so would be an infrequent cost. ($30-$50 per alarm, without
wholesale pricing)
● Paper and ink costs associated with extra checklists and fall signs posted. (4-9 cents
per printed checklist)

Analysis
● An estimated total of $24 9/100 C per shift and an additional $X (depending on
how many bed alarms are needed, at 20 beds on the unit the max would be
$50per alarmx20beds=$1000)
● With this in mind, we feel that the benefit to implement our plan far outweighs
the costs associated with the implementation, and could potentially save the
hospital/unit an exorbitant amount of money related to falls
 Timeline
● 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 May
1st 2024.
● Start the program by May 15th
2024.
● Evaluate efficacy on August
1st, 2024 (giving 2.5 months of
trial) to see if falls have
decreased.
Data Collection
● Compare fall rates monthly
(with each other and
pre-implementation months
for the last year).
● 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.
Conclusion
● The implementation of a fall safety champion is a simple, cost
effective way to increase unit safety, while simultaneously reducing
patient morbidity, hospital stay length, and will help mitigate
expenses related to patient injuries due to falls.
● Requiring the use of all fall preventative measures for every patient
could assist in reducing falls at least before PT/OT teams are able to
see the patient and assess the individual needs of each patient.
● If 1 in 4 falls results in injury, this is an issue that continually needs
“Fall prevention is important in any health care setting as
to be addressed and advocated for by staff. a means of improving patient safety.”
● Hopefully with implementing these presented preventative
measures, over the next year, CVSU will see a decrease in fall
prevalence.
(Szumlas, S., Groszek, J., Kitt, S., Payson, C., & Stack, K., 2004)
References
Carroll, C., & Eberlein, B. (2023, November 23). Q: How can we help nurses prevent patient falls without increasing their workload? A:

Use a predictive model to identify patients with a high risk of falling. EpicShare.

https://www.epicshare.org/tips-and-tricks/prevent-falls

LeLaurin, Jennifer H., and Ronald I. Shorr. “Preventing Falls in Hospitalized Patients.” Clinics in Geriatric Medicine, vol. 35, no. 2, 1

Mar. 2019, pp. 273–283, www.ncbi.nlm.nih.gov/pmc/articles/PMC6446937/, https://doi.org/10.1016/j.cger.2019.01.00

Preventing and Managing Falls in Adults with Cardiovascular Disease. (n.d.). American Heart Association.

https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/preventing-and-managin

g-falls#:~:text=Cardiovascular%20conditions

Szumlas, S., Groszek, J., Kitt, S., Payson, C., & Stack, K. (2004). Take a second glance: A novel approach to inpatient fall prevention.

The Joint Commission Journal on Quality and Safety, 30(6), 295-302.