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
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Primary Objective: Reduce inpatient falls by 30% within 12 months of implementation.
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Secondary Outcomes:
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Achieve 100% completion of fall risk assessments within 2 hours of admission.
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Achieve 95% compliance with implementation of fall prevention interventions for high-risk patients.
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Reduce the rate of fall-related injuries by 20% within the first year.
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Roles Impacted by the Policy
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Nursing Staff (RNs, LPNs, CNAs)
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Nurse Educators
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Patient Care Technicians
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Physicians and Advanced Practice Providers
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Physical and Occupational Therapists
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Quality Improvement and Risk Management Teams
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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:
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Conducted within 2 hours of admission, after any change in condition, transfer, and every 12-hour shift.
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Use a validated tool such as the Morse Fall Scale or Hendrich II Fall Risk Model.
2. Identification of High-Risk Patients:
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Patients scoring above the threshold on the fall risk tool will be classified as high risk.
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Place yellow wristband, fall risk signage, and bed alarms accordingly.
3. Fall Prevention Interventions:
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Keep bed in low position with brakes locked.
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Call light within reach and encourage use.
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Scheduled toileting rounds every 2 hours.
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Use of non-slip socks and appropriate footwear.
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Supervised ambulation as needed.
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Implement hourly rounding to assess “4 Ps” (Pain, Positioning, Potty, Possessions).
4. Education and Communication:
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Educate patients and families on fall risk and prevention strategies.
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Interdisciplinary communication during handoff reports must include fall risk status.
5. Post-Fall Protocol:
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Immediate medical assessment and injury evaluation.
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Complete fall incident report within 2 hours.
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Root cause analysis (RCA) for falls with injury.
Policy Review and Revision Frequency
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This policy will be reviewed annually or sooner if new evidence or data trends suggest a need for change.
Oversight and Monitoring
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Responsible Parties:
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Quality and Risk Management Department
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Nursing Leadership (Unit Managers and Chief Nursing Officer)
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Fall Prevention Committee
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Effectiveness Metrics:
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Monthly fall rate per 1,000 patient days.
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Number of falls with injury.
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Compliance with fall risk assessments and interventions.
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Staff adherence to documentation and rounding protocols.
Audits and Monitoring:
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Weekly audits of fall risk documentation.
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Random checks for intervention compliance.
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Monthly review of fall data and trends at unit-based safety huddles.
References
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The Joint Commission. (2023). National Patient Safety Goals: Hospital Program. https://www.jointcommission.org
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Agency for Healthcare Research and Quality (AHRQ). (2022). Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. https://www.ahrq.gov
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Centers for Disease Control and Prevention. (2022). STEADI – Older Adult Fall Prevention. https://www.cdc.gov/steadi
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Morse, J.M. (2009). Preventing Patient Falls: Establishing a Fall Intervention Program. Springer Publishing.
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American Nurses Association (ANA). (2021). Nursing: Scope and Standards of Practice (4th ed.).