Reducing Geriatric Falls

Project Topic:

Reducing geriatric falls through standardized risk communication and audit feedback

Hospital, City and State:

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

Unit:

• Acute Care for Elders Unit (ACE)/4M

CSI Participants:

• Ayla McCoy, MSN, RN
• Chridacia Rogers, BSN, RN
• Colenthia Smith, BSN, RN

Project Goals/Objectives:

1. Increase the Healthy Work Environment Assessment Tool (HWEAT) True Collaboration” score by ≥10% from baseline
2. Reduce the unit fall rate by 20% from baseline
3. Increase patients achieving JH-HLM ≥6 (ambulation level) by 10%

Project Outcomes:

1. Decreased HWEAT True Collaboration score from 4.27 to 3.58
2. Decreased falls from 22 to 12 – a 45.5% decrease
3. Decreased patient mobility scores 5.1%
4. These outcomes resulted in a positive estimated annual fiscal impact of $605,257

Project Overview:

The Donut Fall initiative is a nurse-led change project aimed at reducing falls among geriatric patients by improving the reliability of fall prevention practices. The intervention introduced standardized door signage to clearly communicate patient-specific fall risks and mobility needs. The team established a workflow for updating signage each shift.

The CSI team partnered with the Geriatric Quality Team (Geriatric Scholars), who designed and implemented a structured audit and feedback process to reinforce practice consistency, supported by staff recognition strategies.

Results show a reduction in falls (~25%), alongside improved consistency in risk communication. Ongoing efforts focus on sustaining audit processes and strengthening the link between practice reliability and patient outcomes.