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Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): a Patient-Centered Fall Prevention Toolkit
Joint Commission Journal on Quality and Patient Safety
|July 26, 2017
Summary
Implementing the Fall TIPS Toolkit reduced patient falls with injury in hospitals. This evidence-based intervention improved patient safety and knowledge of fall prevention strategies.
Area of Science:
- Healthcare quality improvement
- Patient safety research
- Clinical intervention studies
Background:
- Hospitalized patients are at risk of falls, leading to injury, reduced mobility, and increased healthcare costs.
- The Fall TIPS Toolkit (Fall TIPS) offers bedside clinical decision support, connecting patient fall risk assessments with evidence-based interventions.
- Effective strategies were required to integrate these evidence-based interventions into routine clinical practice.
Purpose of the Study:
- To pilot and evaluate the implementation of the Fall TIPS Toolkit in two major hospitals.
- To assess the impact of the Fall TIPS Toolkit on patient fall rates and fall-related injuries.
- To evaluate improvements in patient knowledge regarding fall risks and prevention.
Main Methods:
- Utilized the Institute for Healthcare Improvement's Framework for Spread for pilot implementation.
- Engaged stakeholders through shared governance, identified unit champions, and conducted staff training.
- Implemented auditing to monitor protocol adherence and patient outcomes.
Main Results:
- Brigham and Women's Hospital (BWH) achieved 82% compliance, with a decrease in mean fall rate (3.28 to 2.80 falls/1,000 patient-days) and fall with injury rate (1.00 to 0.54 falls/1,000 patient-days).
- Montefiore Medical Center (MMC) achieved 91% compliance, with a slight increase in mean fall rate (3.04 to 3.10 falls/1,000 patient-days) but a decrease in fall with injury rate (0.47 to 0.31 falls/1,000 patient-days).
- Patient knowledge surveys indicated improved understanding of fall risks and prevention methods.
Conclusions:
- Engaging hospital and clinical leadership is crucial for translating evidence-based care into practice.
- Barriers to protocol adoption were identified and addressed, offering guidance for broader implementation.
- The Fall TIPS Toolkit demonstrates potential for reducing patient falls with injury in acute care settings.
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