Inpatient falls with harm have severe implications for patients and the health care system. Authors implemented a zero harm approach to falls prevention with multiple strategies including the display of real-time unit-specific falls rates and a root-cause analysis process after falls. The fall rate decreased from 2.03 (baseline period) to 1.12 (1 year later) per 1000 patient-days, and there was an increase in patient safety incident reporting. In a new process to improve the transition of patients from inpatient settings to outpatient mental health (MH) care, RN Transition Care Managers triaged discharge consults, communicated with schedulers and patients pre- and postdischarge, and tracked MH engagement for 30 days postdischarge. Over 55 weeks, 443 consults were placed, with an average 89% success rate. Other articles share innovative QI studies with implications for your own settings.
Marilyn H. Oermann, Editor
