Don’t Drop It Like It’s Hot

Project Topic:

Decreasing patient falls

Hospital, City and State:

Methodist Texsan, San Antonio, Texas

Unit:

Surgical Specialty Unit

CSI Participants:

• William Cortes, BSN, RN
• Luz Garcia, LVN
• Maritza Perez, BSN, RN

Project Goals/Objectives:

1. Decrease the number of falls 33%
2. Increase the scores for collaboration and communication on the Healthy Work Environment Assessment Tool (HWEAT) 5%

Project Outcomes:

1. Falls increased 38%
2. True Collaboration HWEAT score remained unchanged
3. Skilled Communication HWEAT score decreased from 3.80 to 3.58
4. Rate of assisted falls increased
5. No falls with injury recorded

Project Overview:

Due to the patient population on the orthopedic/surgical unit, the need for increased fall prevention and awareness is vital to patient safety. Post fall data and debriefings showed that the biggest opportunities in fall prevention were bed and chair alarm utilization since most falls were unwitnessed/unassisted falls.

Falls increase healthcare costs even if there is not an injury. An unassisted fall can require diagnostics to ensure no injury occurred. If an injury were to occur the costs and length of stay could increase dramatically depending on the severity. Furthermore, any fall that does occur negatively impacts patient experience and the perception of staff's ability to take care of the patient.

From May to December 2023 there were a total of 12 falls. Only 1 fall was assisted, and none were with injury. The CSI team focused on fall prevention specifically on alarm usage for the project. Staff education and reinforcement of the fall bundle were areas of focus within the project and, along with an introduction to the project, was the emphasis of the kickoff event that took place in May of 2023.

While falls for the year did increase from 13 for 2023 to 19 for 2024, our assisted falls increased from 1 to 4. A metric that could not be easily measured was the number of times staff witnessed and stopped patients from trying to get out of bed unassisted which could have resulted in a fall otherwise. Other outcomes of the project included a more overall positive unit staff outlook on fall prevention and recognition of high fall risk patients. Ultimately, more fall prevention barriers were identified which included the need for increased patient education on how to prevent their own falls, which would help post-discharge as well, and reinforcing the need for not leaving patients out of bed unattended such as when they are in the restroom.