Safety Standards: Implementing Fall Prevention Interventions and Sustaining Lower Fall Rates by Promoting the Culture of Safety on an Inpatient Rehabilitation Unit.

PURPOSE

The purpose of this article is to review a quality improvement project aimed to examine how nurse leaders in an inpatient rehabilitation (IPR) unit can reduce the number of patient falls by implementing multiple fall prevention interventions and sustain their results by promoting a strong culture of safety on the unit.

DESIGN AND METHODS

A retrospective review of IPR fall rates was performed. Quarterly fall rates were then compared with implementation dates of fall prevention interventions (safety huddles, signage, and hourly rounding). Culture of safety scores were also examined to assess the effect of an enhanced culture of safety on the sustainability of lowered fall rates.

FINDINGS

The largest decrease in fall rate was noted after initial revitalization efforts of the IPR unit's culture of safety concurrently with hourly rounding.

CONCLUSIONS

Fall rates rise and fall despite multiple fall prevention interventions and encouraging a positive shift in the culture of safety.

CLINICAL RELEVANCE

Physical injuries following a fall can reduce mobility and increase morbidity. Costs associated with falls negatively impact costs and reimbursement. Employing evidence-based fall prevention strategies are then of critical importance to nurse leaders as falls remain an ongoing serious adverse event.