Patient Falls Reduction QI






Patient Falls Reduction QI

Rose Safaro

M8A1 Scholarly Paper

NUR 456
















Nurses, regardless of professional level or designation, will be called on to lead, formally or informally during the course of their careers. Leadership from nurses from the healthcare community is an expectation formally and informally.. According to Adeniran (2013), the Institutes of Medicine’s report The Future of Nursing: Leading Change, Advancing Health released in 2010 emphasized the need for development of leadership programs that results in nurses having the ability to be leaders or change, and advance health and health care through the creation of innovative initiatives that provide opportunities for education and professional growth.

In the scenario provided for this assignment, a Bachelor’s prepared nurse has been asked by the Director of Surgical Services to lead a quality improvement (QI) project to reduce the number of falls with injuries within this division of the organization. It has been determined that the surgical division has a rate of 5.0 falls per 1,000 patient days in the first quarter of this year with three of these falls resulting in serious injuries. According to the Agency for Healthcare Research and Quality AHRQ (2019), falls occur at a rate of 3–5 per 1000 bed-days according to epidemological studies. In addition, the AHRQ (2019) estimates that 700,000 to 1 million hospitalized patients fall each year in the United States. Based on this data, the falls which are occurring in surgical division are in sync with the data obtained from epidemiological studies. The Bachelor’s prepared nurse will assemble an interdisciplinary team to address the problem using the Plan Do Study Act quality improvement model to address this problem.

Long Term Impact of Patient Falls

According to Sentinel Events Alert (2015), “Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission’s Sentinel Event database*, which has 465 reports of falls with injuries since 2009, with the majority of these falls occurring in hospital”. Depending on the age and physical condition, the long term impact of patient falls can range from head injuries, to hip fractures as well as temporary damages to other bones and areas of the body (Centers for Disease Control and Prevention, (CDC), 2018). Long term impacts of patient falls can result in head trauma, permanent damage to bones or other body systems and even death (Bouldin et al., 2013; CDC, 2018). There are also financial impacts due to falls. In the year 2015, the total medical costs for falls were more than $50 billion with Medicare and Medicaid assuming 75% of these costs (CDC, 2018). Falls also negatively affect family members and can cause fear of falling in the future (Bouldin et al., 2013; CDC, 2018).

Team Process

According to the Robert Wood Johnson Foundation (2010), one of the most effective way to achieve the goals of health care organization is to understand the need for multiple providers and the development of “…well-functioning teams”. According to the Institutes for Healthcare Improvement (IHI) (2020), forming a team starts with determining the aim of the improvement goal and then aligning this goal with the right people. According to the IHI (2020), determining the aim is essential to the process because it provides the underlying and overlying reasons for the actions that will be taken to make improvement. The the Worksheet for Forming A Team (courtesy of the IHI, 2020), will be used to form the team and team process;

Worksheet for Forming Team

Aim: Reduce the number of falls on the surgical unit by 50% in 6 months


  • Clinical Leader: Bachelor’s Prepared Nurse
  • Technical Expertise: Surgeon, Anesthesiologist, Operating Room Nurse, Pharmacists
  • Day-to-Day Leadership: RN, Nurse manager,
  • Additional Team Members: Certified Nurse Assistants, Staff Nurses, Staff Educators, Patient Educators, and Information Technology experts
  • Sponsor: MD, Chief Medical Officer

Rationale For Team Members

The rationale for having a clinical leader as a Bachelor’s prepared nurse is that leadership will be needed throughout this nurses career and therefore experience in needed. In additional, the need for clinical leadership is that clinical leaders make front line decisions which affect everyday functions in healthcare settings that determine quality and efficient care through the use of technical knowledge. Through this role, clinical leaders are able to make viable strategic decisions regarding patient care delivery (Daly, et al., 2014). The need for the technical expertise of surgeons, anesthesiologists, operating room nurses, and pharmacists can be rationalized because these team members can answer questions regarding patients’ changes health status due to surgeries in addition to the effects of medications on functioning which may related to the tendency for patients to be vulnerable to falling (de Jong, Van der Elst, & Hartholt, 2013; Shorr et al., 2014). The day to day leadership of RNs and nurse managers can be rationalized because like the Bachelor’s prepared clinical leader, they two are part of up front management who can contribute their observations and actions in the process along with tracking or monitoring the implementation and effects of the initiative. Day to day leadership with nurses on the unit is a given because of the need for consistency in the monitoring of the QI. The additional team members of CNAs, RNs, Staff Educators, Patient Educators, and Information Technology experts are needed because of the support role they provide in implementation of the QI (Shorr, 2014). Finally, the rationale for having a MD Chief Medical Officer on the team is organizational support of the project which includes funding.

Characteristics of a Successful Team

In addition to selection of the appropriate team members based on knowledge, skills and abilities, there are other characteristics which are important in order for the team to be successful. According to Bollen, Harrison, Aslani, van Haastregt (2018), based on the results of a systematic literature review which was conducted to examine the components that effect positive interprofessional collaboration between community pharmacists and general practitioners (GPs) using 37 articles from databases such as MEDLINE, co-location and other resources which foster clear and regular communication along with respect, and understanding of each professionals capacity were found to be important for team function.

Leadership style is another consideration as a element for successful teams. Although collaboration is important which often means input from many team members during the process, leadership of the team is important. According to Cardiff, McCormack and McCance (2018), person-centered leadership which is based relational leadership theory which separates individuals from hierarchical structures and focuses on a caring relationship being formed. This type of leadership which is considered person-centered, is a good way to build coalitions between staff members through respect and empowerment (Cardiff, McCormack & McCance, 2018). According to Coleman (2018), in the business and political worlds, relational leadership is often used because it paves the way for compromises to be made.

However, there are other leadership styles that any leader or manager has to be aware of and know how to use. According to Belasen, Eisenberg, and Huppertz (2016), transactional and transformational leadership tactics are often needed to achieve balance. Transactional leadership is synonymous with a give and take attitude i.e. I do for you, you do for me while transformational leadership centers on providing vision and inspiration to staff members. A mix of flexibility and control between values, vision setting, high risk tolerance, hands on coaching, and more are needed for one to be a successful leader in healthcare settings which involves leading and managing interprofessional teams (Belasen, Eisenberg, and Huppertz, 2016).

Quality Improvement Process

Using the PDSA Model (see Appendix A) as framework in QI processes, nurse leaders can anticipate and track the results as the QI proceeds forward in the movement towards change (Agency for Healthcare Quality and Research (AHRQ), 2013a). The P or plan concept in the PDSA model is the second most critical for success in change because at this stage, objectives are defined, questions are asked as predictions can be made by identifying who, what, where, when and through using data that is collected prior to the QI. At the D or do stage, the QI is carried out. After the D stage is the S stage where the process and results are analyzed. At the S stage the developers and participants of the project can ascertain whether or not the QI activities will achieve success if implemented on a broader level. Barriers and facilitators of the change for the QI that is being implemented can be made known and eliminated. At the S stage, changes to the QI plan can be made with clearer objectives and the steps needed to take to make the QI a success. The S stage of the PDSA model is critical to the QI because it precedes the A stage. The Act stage refines the plan before it is implemented based on information gathered at the S stage and becomes the final QI that will be carried out on a broader level (Institute of Improvement in Health, 2020). This is based on the modifications that are identified at the S stage. To be succinct, the observations which are made during the S stage align the PDSA model with the scientific method making it more likely that the QI is based on evidence instead of speculation based. The specificity and scientifically grounded methods used in the PDSA model makes it is an appropriate change model to use in for the fall prevention program being developed.


Plan: Review Cause of falls

Prior to planning for this QI is to figuring out the cause of the falls in the surgical services unit. According to Cuttler, Barr-Walker and Cuttler (2017), “Inpatient falls and subsequent injuries are among the most common hospital-acquired conditions with few effective prevention methods”. Based on this assertion, patient falls is something that can and should be anticipated. The key is addressing this reality with a contingency plan. According to Bouldin et al. (2013), the National Database of Nursing Quality Indicators (NDNQI) defines a fall “… as an unplanned descent to the floor or other lower surface with or without injury to the patient that occurs in an eligible nursing unit”. Falls may be linked to patient (fainting) due to the effects of pharmaceuticals, weakness in limbs and lack of balance due to medical conditions, or environmental (wet floors) factors (Bouldin et al., 2013). Attempts to interrupt the fall is flagged as an “assisted” event and is counted as a fall (Bouldin et al., 2013). In the case of the surgical unit, most of the falls occur due to bed exits and the effects of pharmaceuticals used during surgeries.

Do: Evidence-Based Interventions

Evidence-based interventions to prevent falling range from actions that can be taken on the part of the patient to electronic devices. Many of the interventions focus on older adults. However, due to the lost of balance that may occur due to medications that affect the nervous system post-op, the interventions are relevant.

I ntervention 1: T ai Ji Quan: Moving for Better Balance (TJQMBB) program

Li, Harmer, and Fitzgerald (2016), evaluated the Tai Ji Quan: Moving for Better Balance (TJQMBB) program which was implemented in senior centers. The program serves senior and individuals with disabilities. The TJQMBB progam was developed by Fuzhong Li, Ph.D., a Senior Scientist at Oregon Research Institute. It is a research-based balance training regimen designed for older adults at risk of falling which is also for people with balance disorders according to their website (Tai Ji Quan: Moving for Better Balance, (TJQMBB, 2016). The routines used in the TJQMBB program is based on the 24 movements of Tai Ji Quan (TJQMBB, 2016). Tai Ji Quan improves balance, leg strength, coordination, mobility, postural control, and reduces the fear of falling and has been used in China for hundreds of years (Stevens, Voukelatos, & Ehrenreich, 2014). Based on the results of a follow up on a randomized control the study, the TJQMBB intervention was found to be superior to multimodal and stretching exercises for older adults at high risk of falling which strengthens the clinical use of this . The findings appear to strengthen the clinical use this as a single exercise intervention to prevent injurious falls in this population (Li et al., 2019). The intervention will be used on a volunteer basis for patients in 15 minute sessions per day with a licensed instructor.

I ntervention 2: Morse Scale (See Appendix B)

According to the AHRQ (2013b), the Morse Fall Scale is a valid tool to use for prevention in-hospital falls. The tool can predict falls for hospitalized patients by identifying risk factors and giving them a total score. The total score can then be used by staff to predict falls and plan care accordingly. This tool can be used by staff nurses and it is recommended that it be used in conjunction with clinical assessment of such things as gait and balance along with medication review (AHRQ, 2013b). The tool can be integrated in a patient’s Electronic Health Record (AHRQ, 2013b). In a study designed to assess the ability of the MFS to identify risks for falling in hospital patients, Pasa et al., (2017), found the MFS had the ability to determine a variety of risk factors for falls and was especially good at identifying high risk patients with proper training.

I ntervention 3: 6-PACK F alls P revention P rogram

The 6-PACK Falls Prevention Program is a set of components including low-low beds, bed/chair alarms, a fall-risk tool, “falls alert” signs, ensuring patients’ walking aids are within reach, supervising patients in the bathroom, and scheduled toileting regimes (Barker et al., 2017), In a randomized study using a mixed-methods approach, nurses, Nurse Unit Mangers and other healthcare staff members such as Directors of Nursing, senior physicians and other senior personnel involved in quality and safety or falls prevention were asked questions regarding the suitability of the 6-PACK program. The study took place in 24 wards in 6 hospitals in Australia. The results of the study indicate that the nurses agreed that fall-risk tools, alert signs and low-low beds were useful for preventing falls. However, there were concerns regarding possible injury to staff members with the use of low-low beds. There were mixed views regarding positioning patients’ walking aids within reach and although bed-alarms were considered effective, it was brought out that they are not effective when used with patients in isolation and in situations when too many bed-alarms are rung at one time. Although bathroom supervision was considered beneficial, the participants surveyed pointed out that this was not always practical (Barker et al., 2017). Overall, the participants in the study support the use of the 6-PACK program despite its limitations (Barker et al., 2017).

S tudy

The study criteria for the study that will be used is from the Methods Work Group for the US Preventive Services Task Force (USPSTF) criteria for the internal validity of individual studies (Rugge et al., 2011). The study will be evaluated which using the following parameters for case control studies to determine cause and effect relationship ;

  • “Accurate ascertainment of cases
  • Nonbiased selection of cases/controls with exclusion criteria applied equally to both
  • Response rate
  • Diagnostic testing procedures applied equally to each group
  • Measurement of exposure accurate and applied equally to each group
  • Appropriate attention to potential confounding variables”.

Internal validity determines the cause and effect relationship between variables which in this case is patient falls and effects of the interventions used on the reduction of falls.


A 50% rate of fall reduction will be used as acceptable measure of effectiveness for launching the QI with continual monitoring and moderation for improvements for each intervention.





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Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors. Retrieved from

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Appendix A






















Appendix 2



Item Score

Patient Score

1. History of falling (immediate or previous)

No 0

Yes 25


2. Secondary diagnosis (≥ 2 medical diagnoses in chart)

No 0

Yes 15


3. Ambulatory aid

None/bedrest/nurse assist Crutches/cane/walker







4. Intravenous therapy/heparin lock

No 0

Yes 20


5. Gait









6. Mental status

Oriented to own ability

Overestimates/forgets limitations





Total Score‡: Tally the patient score and record.

<25: Low risk

25-45: Moderate risk

>45: High risk


* Weak gait: Short steps (may shuffle), stooped but able to lift head while walking, may seek support from furniture while walking, but with light touch (for reassurance).

† Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down; significantly impaired balance, requiring furniture, support person, or walking aid to walk.

‡ Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse herself said that the appropriate cut-points to distinguish risk should be determined by each institution based on the risk profile of its patients. For details, see Morse JM, , Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging 1989;8;366-7.


Courtesy of the AHRQ 2013b

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