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Solutions for Patient Safety Fall 2020 Learning Session Abstracts

A Quality Improvement Project to Decrease Falls on In-patient Pediatric Units

Chhipa, Aalya K. BSN*; Chan-Galapon, Monina MSN

Author Information
Pediatric Quality and Safety: March/April 2021 - Volume 6 - Issue - p e447
doi: 10.1097/pq9.0000000000000447
  • Open


Child and adolescent cognition and development make falls prevention a challenge. From June 2018 to May 2019, the rate of pediatric in-patient falls was 1.00 falls per 1,000 patient days. A retrospective analysis of falls revealed an opportunity to better engage patients and caregivers in fall prevention.


Implement initiatives to decrease the in-patient pediatric falls rate to <0.92 falls per 1,000 patient days.


A Fall Prevention Poster was created that visualized fall risk factors from the Humpty Dumpty Falls Scale on the left side and fall prevention interventions on the right side. Risk factors and interventions applicable to the patient were marked, prompting a dialog between the nurse and the patient/caregiver. The Fall Prevention Poster was added to the existing SPS bundle elements and implemented in June 2019. Process measures were reviewed daily through tiered huddles and communicated visually on unit-based goal boards as part of the daily management system.


Postimplementation, from June 2019 to January 2020, fall rates decreased by 19%. The greatest improvement was seen in the medical-surgical units where fall rates decreased 21%. Fall rates in the ICUs remained virtually unchanged. The Cardiology/Neurology unit experienced a 67% decrease (Fig. 1).


It is possible to reduce the falls in pediatric populations through enhanced patient/family engagement and utilizing local management systems. Sustainability can be achieved through consistent monitoring of process measures. Experience with a single-patient population may not be applicable to other patient populations (eg, adults).

Fig. 1.
Fig. 1.:
Preintervention and postintervention fall rates on pediatric in-patient units.
Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.