Document Type

Article

Publication Date

Winter 2024

Keywords

quality improvement, PDSA, change management, falls, nursing

Abstract

BACKGROUND: Falls are a common concern in hospitalized adult patients affecting quality of life, length of stay, and cost.

LOCAL PROBLEM: A quality audit at a community hospital identified increased falls/falls with injury rates on a medical-surgical unit.

METHODS: A quality improvement initiative was implemented using a fall prevention toolkit to understand its effect on total fall/fall with injury rates, nursing knowledge, and nurse perceived efficacy.

INTERVENTIONS: The Fall Tailoring Interventions for Patient Safety (TIPS), an evidence-based toolkit, was implemented over five months.

RESULTS: Knowledge quiz scores were similar pre- and post-education. Fall rates and calls to the nurse for fall information decreased, though changes in these metrics did not reach statistical significance (p=0.88, p=1.00). Fall TIPS poster information was valued by the team and contextual factors influenced project implementation.

CONCLUSIONS: Implementation of Fall TIPS may decrease total fall/fall with injury rates. Contextual influences are important in quality improvement initiatives.

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