Article Content

Inpatient falls potentiate a magnitude of consequences affecting patient outcomes, financial viability for a system, nursing quality, and patient satisfaction. A root cause analysis that included a hospital policy review and literature search identified that a quaternary hospital lacked process standardization and had vague policies on clinical initiatives, poor compliance with utilization of resources, and knowledge deficits. Instead of progressing toward the hospital goal of 35% reduction, many units were experiencing increased falls. A goal set for the clinical nurse leaders (CNLs) was to lead a fall prevention initiative across 8 medical-surgical units. Baseline data were obtained prior to implementation, which included fall data and a survey assessing the staff's knowledge base concerning falls, the falls policy, and fall rates. The strategy included standardized teaching, finalizing qualifying criteria using evidence-based practice, a fall bed alarm, 3-dimensional high-risk wall signage, and a CNL Bed Alarm Visual (CBAV) bundle. More than 50% of the nurses completed the pre- and posttest surveys. There was a 23% reduction in fall rates during this 9-month initiative, which exceeded the goal of 15%. It was noted that 86% of patients who had fallen met the criteria for the CBAV bundle, but only 40% had all components of the bundle in place during the fall. This reflects strong predictability of the newly established criteria and benefits of full compliance. This successful initiative was spread hospital-wide and incorporated into policy. Fall prevention must be multifactorial with accurate risk assessment, standardized education, and staff accountability. Initiatives that use the CNL to improve compliance at the bedside ensure care quality.