Preventing Falls Among Behavioral Health Patients

Area of Science:

• Healthcare Quality Improvement
• Patient Safety
• Behavioral Health Nursing

Background:

• Inpatient falls are common hospital incidents with significant patient and organizational implications.
• Adult behavioral health inpatients experience higher rates of injurious falls, challenging traditional prevention strategies.
• A specific unit observed an increased rate of major fall-related injuries over three months.

Purpose of the Study:

• To describe the redesign of a fall prevention program for adult inpatient behavioral health settings.
• To utilize evidence-based practice (EBP) and quality improvement (QI) methods in program redesign.
• To address the unique challenges of fall prevention in this patient population.

Main Methods:

• Conducted root cause analyses (RCAs) on all major fall-related injuries.
• Performed a literature review to identify EBP recommendations for behavioral health fall prevention.
• Developed a four-element action program: RN education on Morse Fall Scale, individualized patient plans, revised workflows, and improved communication.

Main Results:

• Achieved zero fall-related injuries for six months post-implementation.
• Sustained zero fall-related major injuries for 12 months.
• Demonstrated sustained reduction in major fall-related injuries over a 21-month period.

Conclusions:

• An interprofessional team approach integrating EBP and RCA effectively redesigns fall prevention programs.
• The implemented program successfully reduced major fall-related injuries in adult inpatient behavioral health settings.
• This quality improvement initiative highlights the effectiveness of targeted interventions for high-risk patient populations.