Patient Care Quality and Safety Project
Fall Risk Protocol Determine if patient is a high fall risk-
Conley Scale— (2 times per shift) Score of 2 or higher
Implement Interventions: Identifiers, environmental modifications, education
If needed apply advanced fall precaution measures
Who Will Improve This Process?
The Fall Prevention Team: Nursing, case management, pharmacy,
environmental services, transport, PT, OT, RT, and patient care-techs are all represented
Interdisciplinary team, involving all staff members, rather than only direct-caregivers
Staff education to answer call lights Staff meetings regarding fall protocol Family education
Process Breakdown
Clothing and patient identifiers yielded the lowest percentages of implementation
Advanced data excluded
PDCA -Plan Fall risk bundle Rounding- setting new standards Communication/Education Floor Recognition/ Encouragement
PDCA -Check
Implement check list during rounding and document: If required materials and education were
employed Reinforce Clutter-free environment
Decreased incidence of falls unit and hospital wide
PDCA -Act Increase bundle awareness or
implement Ensure completeness of bundle Make rounding specific to fall
prevention Develop new charting template
specific to fall prevention materials Update fall prevention protocol