Decreasing Falls through Shared Governance

Abstract

In October 2018, at the unit based forum meeting, clinical nurses evaluated patient fall rates and noticed an increase in patient falls in the Q3 2018. The Q3 2018 fall rate was 6.20. Then nurses analyzed each fall including reviewing CCTV to determine possible causes. One of the falls was due to a slip in the shower. The shower floor was tiled and became slippery when wet. Additional falls occurred in the hallway of the unit and possible causes included reality distortion, unsteady gait due to age, medications, and physical condition. In some cases they noticed the CCTV did not capture a fall because there was no camera in that section of the hallway. The clinical nurses discussed this information with the Clinical Manager, at the November 2018 staff meeting. They suggested re-surfacing the floor to prevent slipping, additional cameras mounted in the hallways, and a second monitor at the other nurses station in an effort to prevent patient falls. After implementing these interventions along with CCTV monitoring the fall rate for Q1 2020 was 2.07 and Q2 2020 was 2.66. Through shared governance, evidence based practice implementation and environment of care enhancements the fall rate decreased by 40%.