Preventing Falls Among Behavioral Health Patients

Abstract

Background: Inpatient falls are among the most common hospital incidents reported. Fall-related injuries have significant implications for patients, staff, and organizations. Adult behavioral health inpatients are responsible for higher rates of injurious falls and challenge traditional fall prevention methods. An inpatient behavioral health unit in an acute care hospital identified an increased rate of injury from falls per 1,000 patient-days in three months; three falls resulted in major injury.

Purpose: The purpose of this quality improvement (QI) report is to describe the redesign of a fall prevention program for adult behavioral health inpatients using evidence-based practice (EBP) and QI methods.

Methods: Root cause analyses (RCAs) were conducted on all three fall-related major injuries. Concurrently, a literature review identified EBP recommendations for fall prevention on behavioral health units. A fall prevention action program was developed consisting of four elements: RN education to improve Morse Fall Scale scoring, individualized fall prevention patient plans, revised staff workflow, and improved fall prevention communication.

Results: There were no fall-related injuries for six months and no fall-related major injuries for 12 months following implementation of the fall prevention program. Overall, this reduction in fall-related major injuries was sustained over a 21-month period.

Conclusion: An interprofessional team approach using EBP and RCA is effective in redesigning and implementing a fall prevention program for the adult inpatient behavioral health population.