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Maurissa Gooden
Safety Issue
Falls are a major patient-safety concern (Chen et al., 2024). This toolkit provides staff with evidence-based strategies to reduce inpatient falls and fall-related injuries through individualized prevention plans, communication, and consistent implementation (Turner et al., 2022).
RCA KEY FINDINGS
• Communication holes
• Inconsistent prevention equipment use
• Toileting needs
• Impaired mobility/ generalized weakness
• Lack of individualized interventions
EVIDENCE-BASED STRATEGIES
Individualized fall prevention plans (An et al., 2025)
Strengthen fall risk assessment and reassessments (Turner et al., 2022)
Strengthen communication during handoff reports (Turner et al., 2022)
SAFETY IMPROVEMENT PLAN
Days 1–30 → Review policies and standardize (Sultana et al., 2025).
Days 31–60 → Educate and implement interventions (Sultana et al., 2025).
Days 60–90 → Audit compliance and evaluate outcomes (Sultana et al., 2025).
ORGANIZATIONAL RESOURCES
Nursing | Educator | Leadership | Safety Reporting Systems | QI Department
Implementation resources
AHRQ Fall TIPS
(Dykes et al., 2020) — Fall TIPS toolkit that focuses on creating individualized fall-prevention plans; useful for assisting nurses with assessing patient-specific fall risks and implementing appropriate prevention interventions.
https://psnet.ahrq.gov/issue/preventing-falls-hospitals-toolkit-improving-quality-care
Joint Commission
(The Joint Commission, 2015) — Patient-safety recommendations for preventing falls and fall-related injuries; it's useful for helping staff with additional education, prevention practices, and review of fall events to determine opportunities for improvement.
https://www.jointcommission.org/en-us/knowledge-library/newsletters/sentinel-event-alert/issue-55
Fall prevention practices and implementation strategies: Examining consistency across hospital units. Journal of Patient Safety
(Turner et al., 2022) — Focuses on fall-prevention practices and implementation strategies across hospital units; and is useful for identifying ways to improve staff adherence, and consistency of fall-prevention practices.
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