QI in Action: Preventing Falls in an Acute Surgical Unit

We spotlight Jackie Cosentino’s project focused on falls which is a leading cause of preventable injury in many hospital settings.

The ACHS Improvement Academy’s Quality Improvement Lead (QIL) Program supports healthcare professionals in implementing data-driven improvement initiatives within their organisations.        

At Tasmanian Health Service Hospitals South, reducing patient harm from falls became the focus of a quality improvement initiative titled, ‘Preventing Falls in an Acute Surgical Unit,’ led by QIL Graduate, Jackie Cosentino in an Acute Surgical Unit. 
 

Project Background  

Falls in hospital settings remain a significant patient safety concern, often leading to extended length of stay, adverse outcomes, and reduced quality of life. Within the Acute Surgical Unit, monitoring through nursing and midwifery sensitive indicators highlighted ongoing incidents of patient falls, reinforcing the need for targeted improvement. 

The aim of the project was to reduce patient falls by 20% within six months and eliminate falls resulting in serious injury or death across the Tasmanian Health Service Hospitals South. 

Understanding the Contributing Factors 

Contributing causes of falls were identified, including unfamiliar environments, room design and layout, non-adherence to falls precautions, patient co-morbidities, incomplete falls risk assessments, inadequate room lighting, and other environmental and clinical factors. 

A literature review informed evidence-based falls prevention strategies, including intentional patient rounding and improved falls risk screening processes. Consumer feedback also identified the need for clearer patient education, leading to the co-design of falls prevention posters displayed throughout patient areas. 

Interventions were implemented using multiple Plan-Do-Study-Act (PDSA) cycles to test and refine improvements. Regular communication through weekly newsletters and Staff Safety and Quality board updates helped keep staff informed of progress, audit results, and patient experience data.  
 

Measuring Progress and Impact 

Key measures used to monitor progress included monthly fall rates, severity assessment code ratings, patient experience survey results, and monthly falls risk screening audits. 

At the time of implementation, the project achieved improved compliance with falls risk screening and enhanced patient education, resulting in increased patient awareness and engagement in falls prevention strategies. Consumer satisfaction also improved, particularly in areas relating to nursing care, with patients reporting a better understanding of their individual falls risk and prevention measures. 
 

Sustaining Improvements Across the Health Service 

Building on these outcomes, the team plans to expand intentional patient rounding through the development of a standardised protocol for inpatient units across Tasmanian Health Service Hospitals South, supporting ongoing improvements in patient safety and quality of care. 

Explore projects from QIL Program Graduates      
You can read this full project on pg 13. in the QIL Project Summaries 2024 6th Edition. 

This year's QIL program is underway, but you can register your interest for the next intake. Contact us to see if the program is right for you and how to join the waitlist at improvementacademy@achs.org.au.