Assessing the Effectiveness of a Non-Punitive Fall Prevention Program

Our single-center, quality improvement project evaluated the impact of a fall reduction plan while using a Just Culture Algorithm that included weekly fall reviews involving front line staff using a non-punitive structure. The project has shown successful results.

Prior to starting the program, data at this institution indicated falls were higher than the national fall rate of 3-5 per 1000 patient days. To achieve the goal of reducing the fall rate to below 3.1, an interdisciplinary fall committee was formed, consisting of nurses, nursing leaders, patient care technicians, pharmacists, and physical therapists. The committee operated in a non-punitive format and included all staff members directly involved in fall-related incidents. Protocols for implementing an evidence-based prevention program were developed to (1) address environmental concerns, (2) educate clinical workers and patients' families, (3) enforce interventions, (4) conduct weekly non-punitive, round table discussions, and (5) provide leadership support. Measures were implemented to proactively prevent falls. Data was collected and reported to all departments monthly.

Following implementation of the program, results showed a statistically significant decrease in average fall rates per 1000 patient days from pre-intervention (4.05) to post-intervention (2.54) (P = .0001). Results showed improvement below the national average (3-5 falls per 1000 patient days), resulting in cost savings for the institution due to fewer falls. Inpatient medical-surgical and progressive care units had a noteworthy decline in the total number of falls, with notable estimated cost savings.

Preventative interventions have shown effective results with compassionate, non-punitive leadership, an interdisciplinary team, and continuous follow-up education. Heeding to the Just Culture Algorithm as the foundation of weekly reviews, staff were empowered to engage in fall reduction strategies. A comprehensive weekly fall review program with ongoing staff education and transparent data reporting yielded a significant, sustained reduction in patient falls, with a substantial cost savings in excess of $1.6 million dollars over the life of the program.