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  1. Farley, Holley MSN, RN
  2. Stepanek, Meghan Esq., MPH
  3. Aquino, Carla DNP, RN
  4. Whalen, Madeleine MSN/MPH, RN, CEN, NPD-BC


Background: Performing post-fall debriefing improves patient outcomes through learning from defects and addresses adherence to fall prevention programs.


Local Problem: While addressing an increase in fall rates, a quality improvement team discovered there was no standardized tool or process for completing post-fall debriefing.


Methods: The team used the Plan-Do-Study-Act (PDSA) process to improve the post-fall debrief tool, with an analysis of pilot using the implementation science RE-AIM framework.


Interventions: Three units with a high focus on falls and an established debriefing culture participated in pilot to generate and standardize a post-fall debrief tool.


Results: Through 2 revisions with end user and champion feedback, the tool was refined to assess any contributing factors to the fall.


Conclusion: Through use of the PDSA cycle, the team established content validity of the post-fall debrief tool. This tool is appropriate for inpatient adult and pediatric scale-up and complementary to current fall risk assessment tools.