Don't Go Chasing Falls

Cedars Sinai Medical Center, Los Angeles, CA

CSI Summary

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CSI Presentation

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CSI Toolkit

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Project Topic:

Decreasing falls

Hospital Unit(s):

6North Stepdown

CSI Participants:

  • Danika Laurel, BSN, PCCN
  • Mark Rue, BSN, PCCN
  • Joyce Serpas, BSN, CMSRN

Project Goals/Objectives:

  1. Decrease incidences of unassisted falls in FY 2022-2023
  2. Reeducate and reenforce the fall prevention bundle protocol
  3. Implement the use of fall video
  4. Increase compliance in the fall prevention bundle protocol
  5. Reinvent staff culture and boost morale

Project Outcomes:

  1. Decreased unassisted falls 50%
  2. Increased compliance with use of the fall prevention bundle more than 60%
  3. 100% of post-project Knowledge, Skills, and Abilities (KSA) survey respondents answered Agree or Strongly Agree
  4. These outcomes resulted in an estimated annual fiscal impact of $107,104.

Project Overview:

In fiscal year 2021-2022, we had 12 unassisted falls on our unit. Knowing that falls bring many unwanted consequences, we found this unacceptable. Implementation of our unit’s fall prevention bundle had been inconsistent, largely due to a knowledge deficit about the bundle.

The CSI team set a project goal to decrease unassisted falls 50%. We surveyed all nurses and clinical partners at our Annual Skills Lab. We hung our Fall Prevention Flyer on each bathroom door in the patient’s room so that the patient and their family members could see it. In January, we began using a Monthly Character Board to show the project results to date and to help boost morale.

We met all of our goals, and importantly, the post-KSA survey results demonstrated that our staff are now more aware of the Fall Prevention Bundle and its importance for post-surgical patients. To help sustain this project, we trained champions to become project owners with a multi-phase rollout that includes data review.

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The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.

The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.