Nurses play an integral role in keeping patients safe. Nearly every
nurse can recall an incident in which a patient fell, and how
devastating this was for the patient, family and for the nurse. A
leading cause of injury during hospitalizations in the United States
is patient falls. At Stanford Health Care (SHC) we have prioritized
falls reduction with noteworthy results.
The SHC Falls Prevention Program uses multifaceted strategies and an
interdisciplinary approach; employing both organization-wide and
unit/patient population specific approaches. Our program focuses on
anticipating antecedents that cause patients to fall and engages
patients and families.
SHC has instituted an organization-wide Falls Prevention Committee
that monitors fall data, call light data, viewing of falls prevention
videos data, and uses storytelling about specific cases to engage
staff and promote transparency.
Staff and patient education
Extensive staff education for RNs and non-RN care
Education for patients and family, including a
fall prevention video that is pushed to every patient via Skylight
TV within four hours of admission.
Use of visual tools to
identify patients at risk: yellow socks, door magnets, and magnets
on patient locater board.
Bedside report, engaging patients and families in safety
Keeping within arm's reach of fall risk patients
Post fall huddles and completion of
detailed Huddle Sheet.
Purposeful hourly rounding while
closely monitoring patients voiding patterns and fluid intake.
Shortened pajama length to prevent tripping.
Unit-based/patient population specific strategies
Monthly meetings with high-fall units with Falls Prevention
Committee Chair and Director of Research to:
unit/population-based action plans.
accountable for a falls rate below the Collaborative Alliance
for Nursing Outcomes (CALNOC) 25th percentile for six
Review every incident of a fall and
discuss alternate prevention strategies.
Examples of unit-based strategies:
training materials for Traveler nurses.
reports for nursing assistance with fall risk score.
Early Mobility evidenced-based practice project.
Falls "reflection tool" completed by the nurse
whose patient fell, who interviews two colleagues about their
fall assessment, prevention strategies and documentation.
Patient contract to always call for the nurse.
Various strategies to enhance teamwork.
blankets for fall risk patients.
2012 showed an 18% decrease in falls from 2011, with several
units realizing over 40% reduction in falls.
falls/1000 patient days was reduced 1.74 hospital-wide, which
approaches the top decile when compared to benchmark.