Problem: The Medical Surgical Unit of BSWH Medical Center in College Station Texas had a 300% increase in falls with serious injury during Jan. 1 -April 30, 2021, compared to the previous two quarters.
Measurement: We used fishbone diagrams and Pareto charts.
Analysis: We looked at root causes of post-fall huddles and combine that with qualitative data from nurse and PCT interviews to fully define the problem and breakdown of communication.
Implementation: Used Huddle Boards to track barriers to using all fall precautions, increased patient-friendly signage regarding assistance in bathroom Standardized RN-PCT communication, and added Fall Risk discussion at Bedside Shift Report Standardized with Physical Therapy language around ‘assistance’, increased standardization of whiteboards in the room to identify fall risk, mobility, and assistance.
Results/Discussion: From May 1- January 2022, the unit had Zero Falls with injury. The unit also significantly decreased the number of falls, with a reduction of almost 60% in comparison to the previous two quarters. This unit also celebrated the success of 67 days without any falls during their interventions.