Prevention of falls, and reducing the risk of harm from falls, is a priority at UCSF. Our falls prevention program is made up of a multidisciplinary team that strives to achieve injury-free outcomes by utilizing a nursing and patient-centered approach. We have reduced injurious falls by 89% to a rate of less than 0.01% and we continue to strive for a rate of zero falls for all patients while they are under our care.
Our goal is to be the leader in creating innovative and sustainable processes to ensure that every patient receives optimal care and remains fall free. Nursing administration and hospital-wide leadership provide strong support for this initiative. We have exceeded our goal of reducing falls by 10% – incidence was reduced by 13% and fall rates fell below the national average. UCSF is committed to implementing and sharing best practices so that patient falls will continue to decrease across the continuum of care.
Front-line Staff Lead the Way
We believe the success of reducing falls begins with staff engagement. Each patient care unit nominates a Fall Prevention Champion whose role is to proactively implement fall prevention strategies by first reviewing their data and ensuring fall prevention measures are implemented at the unit level. Their expertise is shared with colleagues on their units and with other Fall Prevention Champions hospital-wide at monthly committee meetings.
Staff education is central to our ability to provide quality care to our patients and families. It enables us to support a culture of safety by fostering clinical expertise and professional development. Targeted staff education for specific high-risk patient populations is provided to all nurses. Patients and families receive education on how to prevent falls in the hospital and at home. Knowledge is power and nurses at UCSF are utilizing knowledge to make powerful changes in patient care!
Working Collaboratively to Target Specific Populations
Our Fall Prevention Champions are a multidisciplinary team, with members from all care settings and disciplines, working collaboratively to ensure that fall prevention measures are implemented on each unit. In-depth falls analyses are done with multidisciplinary groups to reveal trends and create individualized unit-specific action plans.
Daily rounds are conducted on adults assessed to be at risk for falls and injury and risk assessments are included in hand-off communications as a patient moves across the continuum of care. Fall precautions are implemented proactively on surgical units for every patient who has had surgery within the last 48 hours. Our Falls and Safety Team (FAST) are trained volunteers who round on patients at risk for falls and ensure compliance with fall prevention program components. In addition, we actively collaborate with the UCSF School of Nursing to review the latest research and network with other hospitals to seek out the most innovative best practices.
Data Transparency and Analysis
The Department of Nursing utilizes innovative and sustainable processes to reduce falls by focusing on data evaluation and unit-based, patient population-specific interventions. We continually measure falls rates to identify opportunities for improvement and provide unit-level data in monthly reports. Unit-specific falls analyses and action plans are reported to quality and safety councils and are submitted for benchmarking and public reporting. Falls Prevention Champions conduct monthly falls process measure audits and front-line staff review the data to initiate improvement interventions based on their own units’ results.