Vincent Castelle, BSN, RN & Marissa
Romeri , BSN, RN
Vincent Castelle, BSN, RN & Marissa Romeri , BSN, RN
UC DAVIS HEALTH -QUALITY IMPROVEMENT
Patient fall reduction continues to be a focus across medical-surgical units as falls are the most frequently reported adverse event in the inpatient setting. Nurses play a critical role in identifying which patients are at high risk of falling during hospitalization. South 1 Adult Annex is a 17-bed unit that provides care to medical and surgical patients. The unit is designed as a short-stay unit with all admissions received directly from the Emergency Room. In Fiscal Year 2019 (FY19), South 1 Adult Annex had a total of zero falls. The South 1 Unit Based Practice Council (UBPC) recognized that zero falls for a full fiscal year is attainable and opted to develop a standardized fall risk protocol to help continue preventing patient falls on South 1.
The purpose of the staff education project is to increase nursing utilization of the proper fall assessment tool (Morse Fall Scale), and to initiate the corresponding standardized fall risk protocol. This includes visual fall risk identification, auditory fall risk identification, proper documentation of high fall-risk patients, and corresponding patient/family education.
Design & Methods
The South 1 UBPC, South 1 Quality & Safety Champion, South 1 management team, and the South 1 staff collaborated in developing a falls protocol to help prevent patient falls from occurring by utilizing multiple fall prevention interventions. These fall prevention interventions were modeled after UCDMC North 1 Adult
Annex’s successful fall project, with unit specific modifications made to help develop our standardized protocol. Metrics reflected on Patient Care Services (PCS) Quality & Safety Falls Dashboard were used to measure effectiveness of newly implemented standardized protocol.
The focus of the staff education project is to increase nursing utilization of proper fall assessment tools and initiate the corresponding standardized fall risk protocol complete with visual fall risk identification, auditory fall risk identification, proper documentation of high fall-risk patients, and patient/family education.
• Staff education regarding implementation of new falls protocol.
• Falls assessment at time of admission, start of shift or change in patient condition.
• Utilization of the proper fall assessment tool, Morse Fall Scale (MFS).
• Providing visual fall risk identifiers including fall risk armbands, fall socks, fall bedside posters, fall signage, call lights, and a green light on bed if in lowest position.
• Creation of a “Falls Bin” to house the visual fall risk identifiers all in one place.
• Utilizing the call light and bed alarm for auditory fall risk identification.
• Utilizing Lift Team to assist with mobilization of high fall risk patients.
• UBPC members attended Lift Team Supervisor in-service regarding safe patient handling equipment.
• Adding fall education and fall precautions to pre-shift huddle.
South 1 Falls data prior to intervention:
FY2019 - 0 Falls
FY2020 Q1 - 0 Falls
FY2020 Q2 - 1 Total Falls, 0 Falls w/ Injury FY2020 Q3 - 2 Total Falls, 1 Fall w/ Injury
Results & Conclusions
The monthly, quarterly and annual fall rate data has been collected for FY2019 and FY2020. In FY2019, there were a total of zero falls. In Q1-Q3 of FY2020, South 1 had an uptrend in our fall rate with a total of 3 falls, 1 with injury. We implemented our project at the end of Q3 in FY2020, after our uptrend. After project implementation in Q4 of FY2020, we reversed the trend and brought
our fall rate down to one total fall, zero falls with injury. Based on the data from pre- and post-intervention, we found that the implementation of the standardized fall risk protocol successfully helped reduce fall rates on our South 1 unit.
• 1. King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018, March 19). Impact of Fall Prevention on Nurses and Care of Fall Risk Patients. Retrieved July 20, 2020,
• 2. UCDMC PCS Quality and Safety Dashboard
Manager: Calene Roseman, MSN, RN
ANII’s: Neola Marlene Armstead, MSN, RN, Salvador Mislang, MSN, RN, Didra Pinckney,
BSN, RN, Kirsten Talley, BSN, RN
UBPC Members: Graciela Brooks, BSN, RN, Vincent Castelle, BSN, RN, Kristy Mach, BSN,
RN, Marissa Romeri, BSN, RN
Q&S Champion: Greg Woods, MSN, RN
All South 1 Staff Members