Unit-based fall huddles and Service-line based outlier meetings to review circumstances surrounding falls. Medications review to determine those that most greatly increase risk of falls. Patients not assessed as high fall risk were placed on bed alarms for two hours after receiving these meds. All staff members received education on Crucial Conversations and how to address patients' refusal of bed alarm usage. Continued refusal of the bed alarm was escalated to nursing leadership. Collaboration with Physical Therapyethe use of a communication board to report activity and required assistance by staff. Findings & Interpretation: 2012 total falls were 19, fall rate 3.02/ 1000 patient days. 2013 total falls were 27, fall rate 4.45/ 1000 patient days. 2014 falls through 3 rd quarter is 10, fall rate 2.08/ 1000 patient days. Discussion & Implications: Consistent implementation of any strategy is the best way to ensure sustained results. Nurse leader rounding to validate use of the bed alarm and consistent messaging to staff and patients is necessary to keep protocols high priority. References to be listed on poster presentation
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