Reducing Falls in Hospitalized Children and Adolescents with Cancer and Blood Disorders: A Quality Improvement Journey

Abstract

Background: Falls in hospitalized pediatric patients represent a serious patient safety concern. Children and adolescents with cancer and blood disorders have inherent risk factors that increase the likelihood of injury from falls. The Hematology/Oncology (HO) and Stem Cell Transplant (SCT) inpatient units at Boston Children's Hospital embarked on a multiyear quality improvement journey to reduce inpatient falls in this population.

Methods: A targeted Falls Reduction Task Force implemented key initiatives between 2020 and 2023. These include enhancing communication strategies to heighten awareness of the highest fall-risk patients, conducting a formal apparent cause analysis on every fall with injury, and initiating a physical therapy-led program to reduce deconditioning. Outcome measures were total falls, rate of preventable falls with injury per 1000 patient days, and days between preventable falls with injury. Our quality improvement team used statistical process control charts to track changes over time.

Results: The combined rate of preventable falls with injury per 1000 patient days decreased from 0.63 in fiscal year (FY) 2020 to 0.25 in 2023. The SCT and HO units achieved a maximum of 442 days and 410 days, respectively, between preventable falls with injury in 2021-2023, compared with 124 and 117 days in 2020. The two units observed a 51% reduction in total falls over 4 years.

Conclusions: A multifaceted fall reduction quality initiative effectively reduced preventable falls with injury on pediatric HO and SCT inpatient units, thereby reducing avoidable harm in a vulnerable patient population.

Fig. 1.

Key Driver Diagram. The KDD allowed the Falls Reduction Task Force to identify specific risk factors contributing to falls on the HO/SCT units. The group defined the primary drivers as patient-specific risks, caregiver/care team engagement, and maintaining a safe care environment. Our team identified secondary drivers related to each category. This exercise guided targeted interventions, identified as “Change Ideas.”

Fig. 2.

Days between preventable falls with injury t-chart: The mean days between preventable falls with injury increased to 24.67 days in FY 2021, compared with 8.31 days in the baseline period. Key interventions are annotated in Figure 2 and Figure 3 as follows: A—Falls Reduction Task Force formed (December 19), B—ACA, All Falls with Injury (Jan 2020), C—COVID-19 Pandemic Begins (Mar 20), D—PT Pilot Program on SCT Unit (Jul 2020), E—Patient/family meeting postfall (Sep 2020), F—Expansion of PT Pilot to leukemia patients (Dec 2020), G—Pediatric cardiac chairs on units (Apr 2021), H—New Socks Program on SCT Unit (Dec 2021), I—New Socks Program on HO Unit (Jan 2022), J—Crib safety signage implemented (Mar 2022)

Fig. 3.

Preventable falls with injury rate run chart. The preventable falls with injury per 1000 patient days decreased to 0.25 in FY 2023, compared with 0.63 in 2020, 0.74 in 2021 and 0.42 in 2022. We referenced the same interventions annotated in Figure 2.

Fig. 4.

Annual comparison of falls by category. Based on NDNQI definitions, our team classifies inpatient falls into one of eight categories. Our QI team organizes the H/O and SCT falls by category into Pareto charts. This graph compares the falls annually by category over the 4-year intervention period.