Case Study: St. Luke’s, Monroe Campus 2020 HAP Achievement Award

"I've fallen and I can't get up..." Preventing Inpatient Falls

In an effort to reduce fall rates, the St. Luke’s hospital team took a multidisciplinary approach, focusing on prevention, staff education, and a rigorous review process for each incident.

The newly developed fall prevention team included clinical staff, as well as nutritional services and environmental services staff. The team set an initial goal to reduce inpatient falls to a rate below the Pennsylvania Patient Safety Authority’s benchmark.

The hospital team identified several key strategies to achieve its goal, including:

• Researching and identifying solutions that could be implemented quickly, as well as others that required long-term follow up
• Deploying rigorous data review to identify trends in patient care and bi-monthly meetings to assess the success of patient safety solutions
• Developing and implementing innovative techniques, such as using yellow bands and socks to identify patients with a high risk of falling, and a “Blue Star Awareness Process” to notify staff about patients with cognitive impairments who may have an increased risk of falling
• Incorporating team staff events, such as "No Falls February,” to highlight the new patient safety initiative

Upon launching the program, St. Luke’s Monroe achieved eight months of continuous improvement, with the rate of falls below the Patient Safety Authority’s benchmark. The hospital team continues to work together to maintain its progress.

Learn more about HAP's Achievement Awards program.

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Topics: Quality Initiatives

Revision Date: 8/1/2020

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