Assessing the Effectiveness of a Non-Punitive Fall Prevention Program

Abstract

Background

Our single-center, quality improvement project evaluated the impact of a fall reduction plan while using a Just Culture Algorithm that included weekly fall reviews involving front line staff using a non-punitive structure. The project has shown successful results.

Methods

Prior to starting the program, data at this institution indicated falls were higher than the national fall rate of 3–5 per 1000 patient days. To achieve the goal of reducing the fall rate to below 3.1, an interdisciplinary fall committee was formed, consisting of nurses, nursing leaders, patient care technicians, pharmacists, and physical therapists. The committee operated in a non-punitive format and included all staff members directly involved in fall-related incidents. Protocols for implementing an evidence-based prevention program were developed to (1) address environmental concerns, (2) educate clinical workers and patients’ families, (3) enforce interventions, (4) conduct weekly non-punitive, round table discussions, and (5) provide leadership support. Measures were implemented to proactively prevent falls. Data was collected and reported to all departments monthly.

Results

Following implementation of the program, results showed a statistically significant decrease in average fall rates per 1000 patient days from pre-intervention (4.05) to post-intervention (2.54) (P = .0001). Results showed improvement below the national average (3–5 falls per 1000 patient days), resulting in cost savings for the institution due to fewer falls. Inpatient medical-surgical and progressive care units had a noteworthy decline in the total number of falls, with notable estimated cost savings.

Conclusion

Preventative interventions have shown effective results with compassionate, non-punitive leadership, an interdisciplinary team, and continuous follow-up education. Heeding to the Just Culture Algorithm as the foundation of weekly reviews, staff were empowered to engage in fall reduction strategies. A comprehensive weekly fall review program with ongoing staff education and transparent data reporting yielded a significant, sustained reduction in patient falls, with a substantial cost savings in excess of $1.6 million dollars over the life of the program.

Introduction

According to The Joint Commission, nursing-sensitive indicators (NSIs) are criteria for measuring changes in health status that nursing care can directly affect. Evidence shows that NSIs are reliable metrics to assist with the improvement of clinical practice and the evaluation of nursing care quality.¹ Patient falls are closely monitored NSIs in acute care hospitals due to their direct ties to patient safety.

In the inpatient acute-care setting, fall rates vary widely, but generally occur at a rate of 3 to 11 falls per 1000 patient days.² In the United States, the average is 3 to 5 falls per 1000 patient days.³

Without question, a patient sustaining an injury from a fall is of the utmost concern. According to the Agency for Healthcare Research and Quality (AHRQ), it is estimated that 700 000 to 1 000 000 falls occur among hospitalized patients annually, with approximately one-third of these falls resulting in injury.³ On average, one fall costs more than $14 600 per patient.⁴ Furthermore, if the patient sustains an injury as a result of their fall, their hospital stay can increase by 6 to 12 days on average, increasing financial hardship and creating additional burdens and anxiety for families and staff.²

Causes of falls in the acute-care hospital setting are multi-faceted but are most frequently related to medications, the health of the patient, comorbidities, a recent procedure, generalized weakness, age, and mental health status.^5,6 Clinicians, including registered nurses, certified nursing assistants, physical and occupational therapists, and other members of the interprofessional care team, play crucial roles in preventing falls. Hospitals often implement fall prevention programs, which include patient and family education, staff education, and fall reduction devices, such as chair or bed alarms, gait belts, and special-colored, non-slip stockings. In addition, techniques such as conducting purposeful nursing rounds on patients, ensuring bedside tables and personal items are within reach of the patient, remaining in the bathroom with the patient, and educating the patient to use a call light are common strategies for preventing falls. By some estimates, 80% of falls occur when a patient is unattended in the room or bathroom.⁵

Evidence-based interventions and fall-reduction plans are widely published, with evidence supporting their efficacy.^2,6–10 For example, results of a large multi-hospital, non-randomized trial that implemented a nurse-led fall prevention plan across inpatient nursing units reported a 15% overall reduction in falls over a 3-year period, reducing their fall rate from 2.92 to 2.49 falls per 1000 patient days.⁷ However, while potentially effective, fall prevention methods can have limited success over time unless initiated early in a patient’s stay and involving both the patient and family members.^2,6,7,9 Compliance with plans can also be impacted by patient acuity, staffing concerns, and general staff turnover. Likewise, studies show that practices such as posting fall rates in a public area were more effective than having a post-fall huddle on the unit where the fall occurred.⁸ Helping nurses be empowered and educated improves the quality of nursing care.⁹ Nurses and other caregivers are in a position to help prevent patient falls.

Within our facility, our quality department collects and publishes fall data monthly. As a facility, our goal was to reduce and maintain falls per 1000 patient days to less than 3.1 for our inpatient units, but our rates were higher than the reported average goal. Closer investigation revealed that, at the time, medical-surgical (med-surg) units and progressive care units (PCUs) had the highest rates of falls. Given the history of variable fall rates, the chief nursing officer (CNO) and patient safety director embarked on a plan to reduce patient falls, which included analyzing data from patients who had falls over a 3-year period from 2020 to 2023 at our acute-care hospital.

Methods

The purpose of this single-site quality improvement (QI) project was to reduce fall rates at our inpatient acute-care hospital and, in particular, rates in the units with the highest number of falls. In addition, as a part of this initiative, we attempted to implement a non-punitive culture around fall reporting, designed to empower staff to share concerns. Non-punitive methods included using the Just Culture Algorithm during reviews of events.^11,12 Also, we included front-line staff as a part of the entire implementation, monitoring, and review to aid in the reduction of falls.

Project Setting, Design, Context, and Approval

The setting for the project was an acute-care, inpatient hospital located in the western part of the continental United States. For this project, we used a quasi-experimental, pre-post design. The context for the project was as follows: in quarter 3 of 2021, in response to quality data showing a quarterly fall rate of 4.4 per 1000 patient days (Figure 1), our patient safety director began to closely analyze past quality and fall data. During this review, it was discovered that monthly fall rates as high as 5.9 falls per 1000 patient days (range: 1.8 to 5.9) had occurred in the previous 2 years, despite the hospital’s goal of a maximum of 3.1 falls per 1000 patient days. There was a 17-month pre-intervention period from January 2020 to May 2021, a 13-month implementation period from May 2021 to May 2022, and a 16-month, post-intervention period from May 2022 to August 2023.

Figure 1.

The decline in the facility's quarterly fall rate (per 1000 patient days) from 2020 to 2023 is shown following the implementation of a non-punitive fall reduction program. The fall rate, which initially exceeded the national benchmark, consistently dropped below the benchmark from Q4 2021 onward, indicating the program's success in reducing falls.

Subsequent analysis of fall data from our facility-level occurrence reporting system revealed several trends. A review of fall data identified that the most frequently reported categories of occurrence for falls were “found on the floor,” “assisted to floor/chair/bed,” and “fall while ambulating” (Figures 2 and 3). Further analyses revealed that the top contributing factors reported were “no bed alarm,” and “no fall prevention agreement in place.” Based on this information, we determined that a plan for reducing falls was needed. As noted above, this project was undertaken as a QI project in alignment with a standard health care scope and determined to be exempt from the need for institutional review board oversight.

Figure 2.

A year-over-year decrease in patient falls by location from 2020 to 2023 was experienced following the implementation of a facility-level, non-punitive fall reduction program. Total falls decreased significantly, particularly in the "ambulating" category.

Figure 3.

The graph compares the top 3 fall types before, during, and after implementing the non-punitive fall reduction program from 2020 to 2023. The percentage of patients "found on the floor" increased slightly, while falls during ambulation and those assisted to the floor remained relatively stable, with a slight decrease in ambulation-related falls. Future steps include more focus on the 4 P’s: pain, potty, position, and personal items within reach to see a decrease in these incidents.

Intervention

Following the decision to act, a team was convened to form a plan. The initial team included the facility’s patient safety director, the CNO, the assistant CNO, the vice president of quality, and the director of quality. During the discussions, the elements of the proposed fall reduction program that emerged involved a range of evidence-based practices, which are summarized in Table 1. These practices included 1) designating frontline staff from each nursing unit to serve as fall prevention champions, 2) developing and implementing a fall prevention agreement, 3) reviewing the current fall prevention policy and post-fall huddle process and documentation, as well as 4) reviewing the use of current fall prevention practices. In addition, the planning team voted to create an interdisciplinary Fall Prevention Committee, which would include nurse leaders, frontline staff, physical therapists, and a pharmacist. In addition, the team felt strongly that ensuring that the Fall Prevention Committee was interprofessional in nature was essential for gaining insights from all departments and reducing the potential for bias. The committee was led by the patient safety director and convened weekly for 1 hour.

Table 1.

The Fall Prevention Plan Elements

Intervention #1 Interdisciplinary Fall Committee formed Fall prevention policy developed Post-fall huddle process and documentation created Frontline staff from each nursing unit selected as Fall Prevention Champions

Intervention #2 Fall prevention agreement implemented

Intervention #3 Basic fall-prevention practices implemented: “High-risk fall” sign posted on the patient’s door Yellow non-slip socks Yellow patient armband with date of last fall if applicable Engaged bed alarms Engaged chair alarms Gait belts in all patient rooms Safety rounding with a purpose

Intervention #4 Weekly non-punitive fall review meeting initiated by Fall Prevention Team Just Culture Algorithm used during weekly fall reviews

Intervention #5 Standardized documentation in the electronic medical record used

Development and Implementation of the Just Culture Algorithm

In addition to the practices outlined above, an important element of this plan was the use of the non-punitive Just Culture Algorithm for reviewing patient falls at our facility. Within health care, the term Just Culture refers to one that creates an atmosphere of trust and outlines what is acceptable and unacceptable behavior.^11,12 Endorsed by AHRQ,¹³ Just Culture programs include guidelines for reporting and reviewing patient safety events, and in doing so, act as the bridge between patient safety reporting and a larger culture of safety. ¹² It was important to the Fall Prevention Committee to use the Just Culture Algorithm during fall reviews to allow front line staff to feel safe in describing events surrounding the fall. Ensuring the proposed Falls Reduction Program was not only rooted in evidence-based practices but also modeled the principles of a just culture was important because these principles recognize that competent staff can (and do) make mistakes and that it is critical to ensure staff members are not wrongfully blamed for process or system-level failures. Rooting the program in the principles of a just culture also allowed for increased reporting of near-misses and actual safety events for leaders to follow up on.

Once a fall occurred, the staff involved activated a response team to include the charge nurse of the unit and a nursing supervisor. After the event, the nurse entered an occurrence report in the hospital occurrence reporting system, which was routed directly to the patient safety director, manager of the unit, and director of the unit. Every Thursday, all staff involved in the fall event were invited to the “Thursday Fall Review.” This review was conducted by the patient safety director, unit manager, unit director, CNO, assistant CNO, a pharmacist, and a physical therapist. The patient safety director began the review by informing all participants that it was a non-punitive discussion and the goal was to identify what can be done to prevent a fall from occurring again. Staff members were encouraged to provide insights and contribute to system improvements. Rather than facing reprimand, staff were consulted, counseled, and consoled, recognizing that staff can be emotionally and physically impacted by falls, just as patients are. Support and resources were provided to minimize the second victim effect.

In our roundtable Fall Review discussions, everyone was treated as an equal, with a focus on understanding what happened and preventing future incidents. Processes, policies, action plans, and gaps were carefully considered. Participation was encouraged by all members, and at the end of the review, the patient safety director reviewed findings with the group and then staff were excused, while the remaining team members reviewed events using the Just Culture Decision Tree to determine if the event was best classified as reckless behavior, at-risk behavior, or human error (Figure 4). Depending on which type of risk was identified, the patient safety director worked with the nursing director over the department to determine the next steps. After each fall review, general findings were communicated to the whole leadership team via email later that day, including all staff suggestions for improvement and excluding any punitive action.

Figure 4.

The Just Culture Algorithm utilized for the non-punative fall review to aid in decision making efforts during the non-punative fall reduction program.

Use of Validated Falls Risk Screening Tools

Currently, there is widespread agreement among expert recommendations that fall prevention measures should be implemented based on the results of valid and reliable fall risk assessments, such as The Hendrich II Fall Risk Model™ (HFRM II) or the Morse Fall Scale.¹⁰ These fall risk assessments are predictive tools that use risk factors documented by a nurse to calculate a score for the patient’s risk of falling.¹⁴ In alignment with these recommendations, beginning in April of 2022, nursing staff on our clinical units began using a standardized tool in the electronic health record for assessing and documenting a patient’s risk for falling. Using this standardized documentation in the clinical units created a consistent method for reviewing hospital staff compliance with assessing patients’ fall risk. Following expert recommendations, nursing assessment of patient fall risk occurred upon admission to the hospital, once per 12-hour shift, and as needed, as well as an additional evaluation during any change in patient status or level of care change. For example, if a patient’s condition deteriorated and necessitated transfer to a higher level of care, fall risk was reassessed.

Fall Prevention Agreement

To ensure patients are following fall prevention measures, clinical staff should educate the patient and family members. To assist with patient and family education, the interprofessional Fall Prevention Committee created a Fall Prevention Agreement, which was a document designed to help educate patients and their families about expectations related to falls while the patient was admitted. The agreement included information outlining that the patient is a fall risk, hospital staff expectations for the patient, and what the patient/family could expect from us to help prevent falls while in the hospital. The nurse reviewed it with the patient/family, and the patient or family member signed the agreement at the time that the patient was determined to be a high fall risk. The signed document was placed in the medical record, and a copy was given to the patient.

To easily identify that a patient was a moderate or high fall risk, the committee agreed upon basic fall prevention practices, including the use of a high fall risk sign on the patient’s door, yellow non-slip socks, and a yellow patient armband. Bed alarms were to be engaged at all times while the patient was in bed and chair alarms engaged when the patient was sitting in a chair. Gait belts were distributed and placed in every patient room, to be readily available during ambulation. Physical therapy team members performed 1-on-1 training with staff on the proper use of gait belts. During hospital-wide education on basic fall-prevention practices, rounding-with-a-purpose was also addressed. Hourly rounding and scheduled toileting have been found to be inconsistently used in hospitals.⁸ As a result, the Fall Prevention Committee wanted to include the rounding-with-a-purpose strategy as part of the overall fall prevention plan. This included hourly rounding during the day and every 2 hours at night with an emphasis on proactive toileting, never leaving a patient alone in the bathroom and general room safety. During the process, it was discovered that patients with recent falls were not consistently being identified during shift hand-off or when transferring from unit to unit. Falling once doubles a patient’s chances of falling again,¹⁴ so the committee implemented a new strategy in which the date of the last fall was written on a yellow fall risk wristband with a bright marker to further emphasize the increased risk and educated staff of the importance of discussing fall risk during hand-off. A post-fall huddle form existed in the hospital but was inconsistently used. The Fall Prevention Committee amended the form and educated the nursing supervisors on the changes. The nursing supervisors were the gatekeepers of the post-fall huddle form and reported out daily in our Safety Huddle about any fall that had occurred in the previous 24 hours.

All elements of the Fall Prevention Plan (Table 1) were included in the revised Fall Prevention Policy for the hospital. After all approvals were obtained, hospital-wide education was conducted. Thereafter, the Fall Prevention Committee instituted a weekly fall huddle to review all patient falls from the prior week. Attendees included the patient safety director, vice president of quality, CNO, chief medical officer, nursing leader of the unit, nurse, PCT, a pharmacist, and a physical therapy department leader. The patient safety director led all reviews by gathering facts from the team members in a non-punitive fashion and reviewing the post-fall huddle document. Using the Just Culture Algorithm (Figure 4), each fall outcome was reviewed by the team. Front-line staff in attendance were encouraged to speak up. When an adverse event happens to a patient, many people are affected, including the patient, family members, and health care providers. Education was provided at the time as needed. Results of the weekly fall reviews were disseminated to the entire leadership team for ongoing staff education and training.

Trended fall data was reviewed monthly by the Fall Prevention Committee and disseminated monthly and quarterly by the patient safety director to the entire leadership team. It was posted in departments and reviewed by nursing leadership and other hospital leadership committees. Transparent reporting and consistent follow-up are the cornerstones of the program.

Analyses

Statistical analyses were executed using Python 3.12.0 and visualized in Microsoft Excel. No power analysis was conducted as the data analysis was carried out retrospectively. Additionally, 5 fall individuals were excluded from the analysis, as these individuals were under the age of 18 and were not hospital patients. Descriptive statistics were conducted on patient and fall data to gain insights into the population and trends. A 2-sample t-test was chosen as the statistical method to compare pre- and post-test rates, as it met all assumptions required for the analysis, including numerical data, independence, and normality. The test was performed with a 95% confidence interval. In addition, a 2-tailed chi-squared goodness-of-fit test was conducted to compare pre- and post-test rates between inpatient and outpatient units.

Results

Sample Demographics

Data on a total of 651 patients who fell between 2020 and 2023 was available for analysis. Review of the data revealed men (n = 334, 51%) made up a slightly higher proportion of falls than women (n = 301, 46%), (n = 16 unidentified gender, 2%). The median age of patients who fell was 66 ± 18 years (range: 18–100) (Table 2).

Table 2.

Age, Gender, and Care Setting of Patients Included in Non-Punitive Fall Reduction Program Analysis (2020–2023; N = 651 patients)

	Pre-falls intervention	Pre-patient days volume	Post-falls intervention	Post-patient days volume
Age category (in years)					X2	P value
18–29	24 (6%)	-	13 (5%)		4.96	.0259
30–49	63 (16%)	-	39 (15%)		9.42	.0021
50–69	120 (30%)	-	86 (34%)		11.24	< .001
70–89	116 (29%)	-	100 (39%)		4.38	.0363
90+	12 (3%)	-	14 (5%)		0.002	.9643
Missing	12 (3%)	-	3 (1%)		61.03	< .001
Totals, by age	396 (100%)	-	255 (100%)		-	-
Gender
Male	199 (50%)	-	135 (53%)	-	22.63	< .001
Female	181 (46)	-	120 (47%)	-	22.16	< .001
Unspecified	16 (4%)	-	0 (0%)	-	18.33	< .001
Totals, by gender	396 (100%)	-	255 (100%)	-	-	-
Care setting
Outpatient and ER	78 (20%)	152 693 (65%)	38 (15%)	182 454 (68%)	21.99	< .001
Inpatient	318 (80%)	82 047 (35%)	217 (85%)	86 535 (32%)	24.92-	< .001-
Totals, by setting	396 (100%)		255 (100%)		-	-
Totals, patient days		234 740 (100%)		268 989 (100%)	-	-

Impact on Falls

Impact on Overall Fall Rates

Differences in fall rates/1000 patient days, before and after the intervention are illustrated in Figure 1, and differences in fall rates over time are illustrated in Figure 5. A review of the data found that, compared to the approximately 17-month pre-intervention period (which ran from January 2020 to May 2021) to the 16-month, post-falls intervention surveillance period (which ran from May 2022 to August 2023), there was a steady decrease in fall rates. Specifically, average falls fell from 4.05 falls/1000 patient days pre-intervention to 2.54 falls/1000 patient days post-intervention (t (32) = 4.381; P = .0001), exceeding our goal of 3.1 falls/1000 patient days. In addition, a review of the data following the intervention showed that fall rates remained below the hospital goal for 9 consecutive quarters (Figure 5).

Figure 5.

The phases of the non-punitive fall reduction program highlight key interventions and their corresponding impact on fall rates throughout the process.

Impact on Med-Surg and PCU Fall Rates

A review of the data from med-surg units and PCUs, specifically, also showed a statistically significant decline in falls (P = .0027). Compared to 2020, total falls for med-surg units in 2023 decreased by 24% (2020, n = 76 falls vs. 2023, n = 58). Similarly, PCU falls decreased by 66% (2020, n =91 falls vs. 2023, n = 31).

Estimated Cost Savings

Using the estimate provided by Dykes et al (2023),¹⁴ we estimated the per-patient cost associated with a fall at approximately $14 600 per 1000 patient days, using this as our estimate and that the fall prevention program started in May of 2021, we calculated an estimated cost-savings associated with falls reduction (Table 3). During 2020, the 291 falls were associated with an estimated cost of $4 248 600. In 2022, falls fell from 274 in 2021 to 185 in 2022, resulting in an estimated savings of $1.6 million over the 2 years. Of note, 79% ($1 299 400) of the hospital’s estimated $1.6 million cost savings occurred in 2022, likely due to the consistency of the program being firmly established as a standard process.

Table 3.

Estimated Cost, Cost Savings, by Year, Associated With a Reduction in Falls Following Implementation of Non-Punitive Fall Reduction Program (2020–2023)

Year
Fall category	2020	2021	2022	2023	Estimated savings to date
Ambulating	38	39	24	20	-
Assisted to floor	44	47	21	19	-
Found on floor	91	86	50	51	-
Other	118	102	90	89	-
Total falls per year	291	274	185	179	-
Estimated cost of fall	$4 248 600	$4 000 400	$2 701 000	$2 613 400	$1 635 200
Estimated savings compared to prior year		−$248 200	−$1 299 400	−$876 000
% of total estimated savings		5.84%	32.48%	3.24%

Notes: The estimated cost savings presented in the table are based on findings from a study by Dykes et al,¹⁴ which estimated the cost of a fall without injury of $62 521 ($64 526 if fall results in injury). After considering the cost of implementing an evidence-based fall prevention program, the authors estimate the net cost of avoiding a fall, per 1000 patient days, at $14 600.

Discussion

Overall, the results of this single-site, multi-year QI project yielded a significant and sustained reduction in falls. The results of data analysis revealed a statistically significant decrease in average fall rates per 1000 patient days from overall pre-intervention data (4.05) to overall post-intervention data (2.54) and have continued to decline (Figure 5). At this writing through quarter 1 of 2024, the hospital overall fall rate was 1.99 per 1000 patient days, far below our goal. In addition, the results of the analysis showed significant decreases in falls in the 2-unit types—med-surg and PCU care—that were most affected.

A key component of this fall reduction plan was the involvement of inter-professional front-line staff in fall reviews the week after they occurred. The reviews were non-punitive in nature and encouraged engagement from all who attended. Initially, during the weekly fall review, nurses and PCTs were hesitant to attend or speak freely for fear of reprimand. Once there was a regular cadence to the meetings and the non-punitive review was used, staff learned that it was a means to help improve care and keep patients safe. They were more willing to speak up and offer suggestions for improvement. An additional important component was leadership involvement. The patient safety director, CNO, and assistant CNO discussed fall data at weekly nursing leader meetings. Fall data was distributed quarterly to all clinical units and discussed with staff. Process improvement and other suggestions from the fall reviews were shared weekly with the entire leadership team. It was important to have all leaders and staff understand the importance of compliance with interventions to prevent falls and the documentation of fall risk in the medical record. Ongoing discussion and reporting have been keys to success.

A review of the cost data suggests that implementation of the program was associated with not only significant harm reduction but also reduced costs. According to a retrospective analysis evaluating both the costs of falls and the implementation of an evidence-based falls prevention program (provided by Dykes et al, which included data from 2 large health systems with more than 900 000 patients and 4.9 million patient days over a 74-month period),⁴ the average cost of a fall can be more than $60 000 per event. If patients sustain an injury during the fall, hospital length of stay can increase significantly, although the results of this analysis call into question whether costs associated with falls with and without injury are significantly different.⁴ Even factoring in the costs associated with the implementation of an evidence-based fall reduction program, the reduction in falls was associated with robust cost-estimated savings in excess of $1.6 million dollars over the initial 3 years of the program.

The Joint Commission recommends that health care organizations foster a strong patient safety culture, provide immediate support to affected staff, and implement comprehensive second-victim support programs.¹⁵ These programs should be evidence-based, inclusive, and regularly evaluated to ensure they meet the needs of health care workers. Our weekly Fall Prevention Program stands out due to the hospital’s commitment to a non-punitive approach, utilization of the Just Culture Algorithm, thorough and consistent support of staff, and the dedication of the patient safety director. During the weekly Thursday Fall Review, everyone is treated as an equal, with a focus on understanding what happened and how future incidents can be prevented. Processes, policies, action plans, and gaps are carefully considered. We take consulting with staff seriously, valuing their expertise and insights. As we listen to staff and address broken policies, practices, and procedures, our fall rates have decreased.

Although the total number of falls declined following the implementation of the program, an interesting finding from this project was the percentage in each of our 3 categories of falls (ambulating, assisted to floor/chair/bed, found on the floor) remained relatively consistent (Figures 2 and 3). The non-punitive fall program has positively impacted fall rates, but it has not significantly affected the types of falls occurring. We believe that more intentional hourly rounding with a focus on the 4 P’s—pain, potty, position, and personal items within reach—will help reduce the most common fall type, which involves patients being found on the floor. By concentrating on these areas, we aim to see a consecutive decrease in such incidents.^16,17

Conclusion

Sustained fall reduction is an ongoing patient safety priority. As one of the most common nursing-sensitive indicators, our hospital took fall prevention very seriously. There are many fall prevention interventions and fall programs that have been published, and there is not a single factor that points to successful fall reduction. Using an interdisciplinary, non-punitive approach with continuous feedback and education to include the front-line staff directly involved in the patient fall event, a significant reduction in falls can be realized. It is our team approach and everyone’s responsibility to keep our patients safe. Transparent data reporting and involvement of front-line caregivers during weekly reviews with ongoing education are keys to sustaining success.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity.