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checklist, fall prevention, falls, quality improvement



  1. Johnston, Madeline BSN, RN, OCN
  2. Magnan, Morris A. PhD, RN


Purpose: This quality improvement (QI) initiative aimed to promote patient safety by improving adherence to an existing hospita-approved fall prevention protocol. Specific aims of the initiative were to evaluate the impact of using a fall prevention checklist on (1) the implementation of a bundle of 14 specific interventions (the fall prevention protocol) and (2) the incidence of falls on participating units.


Methods: A QI team conducted a 26-day fall prevention initiative. Data were collected on day and night shifts for 13 days each. We evaluated the effect of using a new 14-item checklist based on the existing hospitalapproved fall prevention protocol on the nursing staff's adherence to each intervention and on the incidence of falls on the test unit. Oncoming staff used the checklist during change-of-shift handoffs to determine whether all prevention interventions were in place before accepting care of the patient. The incidence of falls was tracked daily.


Results: Thirty-seven nursing staff members (RNs and nursing assistants) participated in the pilot study and completed 90 fall prevention checklists. The most frequently missed intervention was setting the bed alarm, which was set incorrectly 19% of the time. There were no patient falls during the pilot study.


Conclusion: By evaluating staff use of the fall prevention checklist, the QI team identified frequently missed prevention interventions and areas for improvement in the hospital's fall prevention protocol. A more comprehensive test of the fall prevention checklist's impact on fall prevention is needed.