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Creating a Standardized Post-Fall Debrief Tool: A Quality Improvement Project.

Holley Farley¹, Meghan Stepanek, Carla Aquino

¹Office of Nursing Professional Practice, The Johns Hopkins Hospital, Baltimore, Maryland (Ms Farley and Dr Aquino); and Legal Department (Ms Stepanek) and Office of Nursing Professional Practice (Ms Whalen), The Johns Hopkins Health System, Baltimore, Maryland.

Journal of Nursing Care Quality

|October 14, 2022

Summary

This summary is machine-generated.

Developing a standardized post-fall debriefing tool using the Plan-Do-Study-Act (PDSA) process enhances patient safety and adherence to fall prevention programs.

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Area of Science:

Healthcare Quality Improvement
Patient Safety Research
Implementation Science

Background:

Post-fall debriefing is crucial for learning from patient falls and improving fall prevention strategies.
A quality improvement initiative identified a lack of standardized tools for post-fall debriefing.
Increased fall rates highlighted the need for a systematic approach to debriefing.

Purpose of the Study:

To develop and validate a standardized post-fall debriefing tool.
To improve the process of post-fall debriefing in a healthcare setting.

Main Methods:

The Plan-Do-Study-Act (PDSA) cycle was employed to iteratively refine the post-fall debriefing tool.
Pilot testing was conducted on three units with a high focus on falls.
The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was used to analyze the pilot implementation.

Main Results:

The post-fall debriefing tool underwent two revisions based on end-user and champion feedback.
The refined tool effectively assesses contributing factors to patient falls.
The pilot demonstrated the feasibility of standardizing the debriefing process.

Conclusions:

The PDSA cycle successfully established the content validity of the post-fall debriefing tool.
The tool is suitable for scalable implementation in both adult and pediatric inpatient settings.
This standardized tool complements existing fall risk assessment instruments.