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Show Reducing Falls on an Inpatient Rehabilitation Unit BACKGROUND • Patient falls are the most common cause of avoidable patient injury and increased healthcare costs worldwide.1,2 • Approximately one million hospitalized patients fall each year.5 • Increased independence and activity among patients in rehabilitation units further increases the risk.4 • Fall risk is influenced by patient condition, environmental factors, and current interventions.3 • Effective fall prevention requires comprehensive staff training and patient education. METHODS The Johns Hopkins Nursing Evidence-Based Practice Model guided the project's development and implementation. Evaluation measures were developed to assess project outcomes and track fallrelated data. Evaluation Measures: • Pre- and post-implementation survey • Fall knowledge test • Fall data sheet Megan Taggart, BSN, RN, MSN Student Dr. Angela Page, DNP, APRN, PPCNP-BC Theresa Duncan, MSN, RN INTERVENTIONS • Step 1: Present the project and obtain stakeholder buy-in. • Step 2: Review evidence and develop an implementation plan with leadership. • Step 3: Identify unit fall champions. • Step 4: Conduct a pre-implementation survey and provide staff and fall champion training. • Step 5: Implement the fall prevention pilot on the rehab unit with weekly evaluation. • Step 6: Conduct a post-implementation survey and analyze fall rates per 1000 patient days. • Step 7: Review results with leadership for potential hospital-wide adoption. IMPACTS AHRQ Fall Statistics • Improved staff knowledge of evidence-based fall prevention strategies. • Increased staff confidence in implementing individualized fall interventions for each patient. • Enhanced teamwork and collaboration among caregivers to reduce patient falls. • Reduction in number of patient falls on the rehab unit Figure 1 (AHRQ, n.d.) AHRQ Fall TIPS Sheet for Nurses CONCLUSIONS • Evidence-based education combined with individualized fall-prevention interventions improves staff competency, reduces patient falls, and increases patient safety and satisfaction. REFERENCES 1Fall Tips: A Patient-Centered Fall Prevention Toolkit. Agency for Healthcare Research and Quality. (2021, February). https://www.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html 2Morris, M. E., Thwaites, C., Lui, R., McPhail, S. M., Haines, T., Kiegaldie, D., Heng, H., Shaw, L., Hammond, S., McKercher, J. P., Knight, M., Carey, L. M., Gray, R., Shorr, R., & Hill, A.-M. (2024). Preventing hospital falls: Feasibility of care workforce redesign to ptimize patient falls education. Age and Ageing, 53(1), 1–9. https://doi.org/10.1093/ageing/afad250 3Jarden, R. J., Cherry, K., Sparham, E., Brockenshire, N., Nichols-Boyd, M., Burgess, S., Grieve, K., Twomey, B., Walters, J., & Rickard, N. (2024). Inpatients’ experiences of Falls: A qualitative meta-synthesis. Journal of Advanced Nursing, 81(1), 4–19. https://doi.org/10.1111/jan.16244 4Miles, K., Fotopoulos, R., Hutchinson, A. F., Khaw, D., & Hooper, S. (2025). Teach-back communication to decrease falls in inpatient rehabilitation settings: A mixed-methods study. Journal of the Australasian Rehabilitation Nurses’ Association, 27(2), 23–32. https://doi.org/10.33235/jarna.27.2.23-32 5Twibell, K. R., Delaney, L., Siela, D., Coers, G., Davis, C., Drown, C., Kring, K., Duncan, J., & Jones, J. A. (2023). Tailoring fall prevention videos for medical-surgical inpatients: A randomized controlled trial. MedSurg Nursing, 32(3), 170-178. Figure 1 Agency for Healthcare Research and Quality. (n.d.). About Fall TIPS [Article]. AHRQ. https://www.falltips.org/about-fall-tips/ Figure 2 Agency for Healthcare Research and Quality. (n.d.). Patient-Centered Fall Prevention Toolkit [TIPS Instruction Sheet]. AHRQ. https://www.falltips.org/wp-content/uploads/2018/05/3.-Fall-TIPS-instructions.pdf A Quality Improvement Project • Research demonstrates that structured prevention education fosters collaborative team efforts. • Reduced fall rates support phased facility-wide implementation of the fall prevention program to further reduce falls and enhance patient safety. Figure 2 (AHRQ, n.d.) |
