Establishing Fall Prevention Protocols on OB-GYN Unit

Project Topic:

Fall Prevention

Hospital, City and State:

The University of Alabama-Birmingham Health System, Birmingham, Alabama

Unit:

• Gynecology/Oncology (GYNX)

CSI Participants:

• Siann Hayes, RN, ADN
• Raven Hughlett, RN, BSN
• Bria Hutchinson, RN, BSN
• Isabella James, RN, ADN
• Cornesha Smith, RN, BSN

Project Goals/Objectives:

1. Decrease patient falls 30%
2. Increase Healthy Work Environment Assessment Tool (HWEAT) True Collaboration and Skilled Communication standards 6%

Project Outcomes:

1. Decreased falls 9.1% from 11 to 10
2. Increased HWEAT aggregate score and all healthy work environment standards
3. These outcomes resulted in a positive estimated annual fiscal impact of $70,730

Project Overview:

Our unit implemented a comprehensive fall prevention initiative focused on improving staff awareness of patient mobility and strengthening a culture of safety. A key component was the introduction of a clear, easy-to-read “fall prevention one-pager” for each patient. This tool highlighted mobility status, required assistance levels, and appropriate devices, allowing all staff members to quickly understand how to safely assist each patient. By standardizing this information, we reduced uncertainty, improved communication across shifts, and reinforced consistent, patient-specific care practices.

To make the initiative engaging and memorable, we introduced “Carrie the Caterpillar” as our nursing unit mascot. A large caterpillar display was placed on the wall, with fall prevention yellow socks creatively used as her feet to symbolize safety and mobility awareness. This visual reminder helped keep fall prevention top of mind while adding a fun and approachable element to the unit. Alongside this, a fall prevention expert was invited to provide an in-person educational session, focusing on best practices and clarifying the differences between various mobility devices to ensure staff felt confident using them appropriately.

We launched the initiative with a kickoff party to introduce Carrie the Caterpillar and to educate staff on how to effectively use the one-pagers in daily practice. To maintain engagement and encourage ongoing participation, we hosted a second kickoff event featuring a themed potato bar. This follow-up event not only boosted morale but also involved staff in the process of collecting and tracking fall prevention data. Together, these efforts created a supportive, interactive environment that reinforced accountability, teamwork, and a shared commitment to reducing patient falls.

The project resulted in a decreased number of falls. Staff became familiar with the fall risk signs and there was an increase in attendance for the unit-based fall prevention class. “Carrie The Caterpillar” has become a huge hit and staff has become more engaged and focused on decreasing falls.