A quality improvement project on evaluating the effectiveness of implementing a fall intervention checklist during end of shift report on a post–operative unit

Abstract

<p><strong>Introduction:</strong> Falls are a current issue affecting our senior citizens within the hospital setting. A fall may result in patient injuries, increased length of stay, and hospital costs. To prevent patient falls and fall-related injuries, hospitals have implemented fall bundles. The bundles consist of assessment tools to identify those at risk for a fall and the interventions that should be implemented to prevent them from falling.</p> <p><!-- [if !supportLists]--><strong>Methods:</strong> A quality improvement project was implemented based on the DMAIC Six Sigma concept model to assess if implementing a fall intervention checklist at shift change combined with a fall bundle already in place will be beneficial in preventing patient falls on a post-operative unit.</p> <p><!-- [if !supportLists]--><strong>Results:</strong> At the beginning of implementation, per the nursing quality measures, the goal was to have at most 2.76 falls per 1,000 patient days. Post implementation, this goal was exceeded, with more than three falls occurring because of implementing the fall prevention checklist. Each participant received a pre and post-test before and after the implementation of this project to assess their knowledge of fall risk factors and interventions. The participants' pre and post-test scores increased by 16.10%.</p> <p><!-- [if !supportLists]--><!--[endif]--><strong>Conclusions:</strong> Based on the results implementing a fall prevention checklist was ineffective in decreasing the number of patients who falls within the post-operative period.</p>