Patient Safety Initiative

Develop a nursing policy based on a specific patient safety initiative. Include the following:

• The specific patient safety initiative
• Purpose of the policy
• Policy objective – include desired metrics or outcomes
• Identify roles that will be impacted by the policy
• Policy statement
• Policy details – thoroughly describe
• How often will the policy be revised?
• Who is responsible for oversight and monitoring? What will be measured to determine effectiveness of the policy?
• References to support the policy

Document Type/Template

• Word Document

Nursing Policy: Fall Prevention and Patient Safety Policy

Patient Safety Initiative

Reduction of inpatient falls through implementation of a standardized fall prevention program in all inpatient units.

Purpose of the Policy

To minimize the risk of patient falls and associated injuries by establishing standardized protocols for identifying at-risk patients, implementing individualized fall prevention interventions, and educating staff, patients, and families.

Policy Objective

• Primary Objective: Reduce inpatient falls by 30% within 12 months of implementation.

• Secondary Outcomes:

  • Achieve 100% completion of fall risk assessments within 2 hours of admission.

  • Achieve 95% compliance with implementation of fall prevention interventions for high-risk patients.

  • Reduce the rate of fall-related injuries by 20% within the first year.

Roles Impacted by the Policy

• Nursing Staff (RNs, LPNs, CNAs)

• Nurse Educators

• Patient Care Technicians

• Physicians and Advanced Practice Providers

• Physical and Occupational Therapists

• Quality Improvement and Risk Management Teams

• Unit Managers and Charge Nurses

Policy Statement

All patients admitted to the facility will be assessed for fall risk upon admission and at specified intervals. Evidence-based fall prevention strategies must be implemented for all identified at-risk patients. Staff are responsible for adhering to the fall prevention protocol to ensure a safe environment of care.

Policy Details

1. Fall Risk Assessment:

• Conducted within 2 hours of admission, after any change in condition, transfer, and every 12-hour shift.

• Use a validated tool such as the Morse Fall Scale or Hendrich II Fall Risk Model.

2. Identification of High-Risk Patients:

• Patients scoring above the threshold on the fall risk tool will be classified as high risk.

• Place yellow wristband, fall risk signage, and bed alarms accordingly.

3. Fall Prevention Interventions:

• Keep bed in low position with brakes locked.

• Call light within reach and encourage use.

• Scheduled toileting rounds every 2 hours.

• Use of non-slip socks and appropriate footwear.

• Supervised ambulation as needed.

• Implement hourly rounding to assess “4 Ps” (Pain, Positioning, Potty, Possessions).

4. Education and Communication:

• Educate patients and families on fall risk and prevention strategies.

• Interdisciplinary communication during handoff reports must include fall risk status.

5. Post-Fall Protocol:

• Immediate medical assessment and injury evaluation.

• Complete fall incident report within 2 hours.

• Root cause analysis (RCA) for falls with injury.

Policy Review and Revision Frequency

• This policy will be reviewed annually or sooner if new evidence or data trends suggest a need for change.

Oversight and Monitoring

• Responsible Parties:

  • Quality and Risk Management Department

  • Nursing Leadership (Unit Managers and Chief Nursing Officer)

  • Fall Prevention Committee

Effectiveness Metrics:

• Monthly fall rate per 1,000 patient days.

• Number of falls with injury.

• Compliance with fall risk assessments and interventions.

• Staff adherence to documentation and rounding protocols.

Audits and Monitoring:

• Weekly audits of fall risk documentation.

• Random checks for intervention compliance.

• Monthly review of fall data and trends at unit-based safety huddles.

References

1. The Joint Commission. (2023). National Patient Safety Goals: Hospital Program. https://www.jointcommission.org

2. Agency for Healthcare Research and Quality (AHRQ). (2022). Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. https://www.ahrq.gov

3. Centers for Disease Control and Prevention. (2022). STEADI – Older Adult Fall Prevention. https://www.cdc.gov/steadi

4. Morse, J.M. (2009). Preventing Patient Falls: Establishing a Fall Intervention Program. Springer Publishing.

5. American Nurses Association (ANA). (2021). Nursing: Scope and Standards of Practice (4th ed.).

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