Decreasing Inpatient Falls: A Retrospective Analysis with CNS-Led Interventions

Inpatient falls are considered 'never events' that may result in increased costs and adversely affect quality of care. This study describes and analyzes characteristics of inpatient falls collected on a ‘Post Fall Huddle/Event Report’ form used by nursing and Risk Management. Data from a convenience sample of 182 falls were collected over a six month period. Analyses included descriptive and regression models on outcomes of injury and length of stay. Incontinence/elimination, antihypertensive medications, higher census, and any medication change, suggested associations with injury or length of stay. Based on the results several strategies were implemented by CNSs to include in-depth review of circumstances surrounding the fall; education of staff for consistency in the fall protocol; reinforcement of purposeful hourly rounding; and the need for increased objectivity on the Post Fall Huddle/Event Report form. Post implementation the average annual number of inpatient falls decreased by 50%.