Document Type


Publication Date

Fall 11-11-2018



Problem: Patient falls has been associated with increased morbidity, mortality and decreased quality of life. The increase in total patient falls for 2018 relative to 2017, and a spike of 10 patient falls for the month of June 2018 from a baseline of 5.3 falls per month has gained greater attention to reduce patient harm from falls while hospitalized. Prevention of falls minimizes patient exposure to the possibility of being injured. Despite efforts to curtail patient falls, improvement in communication is essential to address the safety issues surrounding improving quality of care practices, and consequentially reduce un-reimbursable hospital costs associated with patient injuries.

Context: The improvement project was implemented in the Medical-Surgical microsystem located at a suburban Level II trauma center. The patient population consist of trauma, orthopedics and general medical-surgical patients where approximately 50% of the patients have a SCHMID fall risk score of 3 or more. Efforts at patient falls prevention has been centered at addressing the root causes of the falls, however the focus on effective communication to raise staff awareness of the urgency of addressing patient risk has not been consistently integrated into the standard practice and emphasized enough during the shift hand off report huddles.

Interventions: The interventions employed in this improvement project were based upon assessment of the root causes of the falls. The interventions were consistent implementation of the fall prevention strategies, communication improvement in disseminating the fall risk patients through listing of the SCHMID scores in the assignment sheet, and verbal communication of the fall risk patients during shift huddles. Safety discussion of adherence to falls prevention practices and highlighting of the fall risk patients increases staff awareness to be mindful of the patients who are at risk for falls and injury.

Measures: Outcome measure of patient falls reduction with a target goal of preventing 1 patient fall per month from a baseline of 5.3 falls per month will be gauged by tracking historical patient falls trend. Another outcome measure is the HCAHPS patient satisfaction indicators with the goal of 4.0 STAR rating from a baseline of 3.5 STAR score. Process measures will be assessed whether adherence in listing of the SCHMID scores is consistently included in the assignment sheet with a goal of 50% compliance. A balancing measure will be evaluated whether the shift huddles were completed within 5 minutes and whether incremental overtime were incurred as a result of the communication plan.

Results: Run chart pattern showed a decrease in total patient falls in the medical-surgical microsystem relative to the total falls within the hospital from 40% in July 2018 to 27% in September 2018. The HCAHPS STAR rating for September 2018 4.5 (prelim.) exceeded the goal for patient satisfaction related to nurse responsiveness and communication. Inclusion of SCHMID scores in the assignment sheet rose to 48.9% in September 2018 from 0% in July 2018, there was a decrease use of fall risk “FR” only at 8.3% in September 2018 from 30% in July 2018, and the use of none-listed was down to 37.2% in September 2018 from 69.9% in July 2018. Shift huddles were kept at 5 minutes and no incurred incremental overtime resulting from inclusion of the communication improvement during the shift huddle.

Conclusions: Improvement in communication during shift huddles in tandem with adherence to the falls prevention protocol resulted in a leveling in the number of patient falls in the Medical-Surgical microsystem whereas other hospital units without the communication improvement showed an overall incline in the number of patient falls starting July until September 2018.