In 2009, William Osler launched a revision of the 2001 Falls Prevention policy. The strategy focused on a comprehensive falls risk assessment, universal and high-risk interventions, reassessment, documentation, evaluation, and ongoing monitoring. While the strategy was embraced, a subsequent review of falls suggested that the implementation had not had the anticipated impact. With the advent of the ECFAA, Osler identified Falls Prevention as a key indicator on our Quality Improvement Plan and provided the much needed impetus for an alternative approach to falls prevention. Over several months in 2011, a project team and front line staff crafted an improvement plan as a secondary layer to the corporate falls strategy. Process mapping exercises were done and transitions of care, patient flow, and team movements were also documented. Based on these activities, the leverage points were prioritized and phased in over a number of months. Thirteen separate interventions were implemented and the rate of falls has dropped from a rate of 11.2 per thousand patient days to a rate of 2.4 in less than four months, and, with two exceptions, has been below the benchmark of 6.1 for a year. Two additional units implemented several of the strategies learned from the pilot area (e.g., purposeful rounding, bedside reports, use of exit alarm frames) and have had similar reductions in the rate of falls.

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