Falls Risk Prevention Bundle to Reduce Falls in an Inpatient Psychiatric Unit

Abstract

Inpatient psychiatric patient falls are a significant patient safety concern that can result in distress, injury, or death. According to a systematic review, multifactorial evaluation and intervention can reduce falls by 20-30%; however, few large-scale implementation studies have been conducted. A fall risk prevention safety bundle quality improvement initiative was implemented and evaluated. Essential components of this multifactorial assessment and intervention included fall risk reassessment after medication administration, bedside shift report, updated patient care plans to correspond to updated falls risk assessment, and daily leadership huddles using a dashboard system is exhibited as a care bundle in this publication. Falls score assessment after medication administration was the core strength of the project, and staff compliance was most notable during this phase. The findings could serve as a knowledge base for unit leaders to develop assessment protocols and establish education and training programs to promote patient safety. The project may inform future projects to make fall risk assessments clinically relevant in inpatient psychiatric settings to reduce fall injury rates.