AHRQ’s Toolkit Helped Vanderbilt University Hospital Substantially Reduce Patient Falls

Vanderbilt University Hospital used AHRQ's Preventing Falls in Hospitals toolkit to reduce falls resulting in injury by 45 percent from 2015 to 2016.

According to Sonya Moore, R.N., M.S.N., C.P.P.S., the hospital's manager of nursing quality, the program was implemented as a collaborative effort with all units working to tackle the problem of patient falls.

"AHRQ's Preventing Falls in Hospitals toolkit was an invaluable resource for our latest improvement work," she explained. "The evidence-based best practices, roadmap, checklists, and templates served as trusted tools throughout our journey."

The hospital used more than a dozen AHRQ tools in its falls-reduction program, including "Overview: The Problem of Falls, Challenges of Fall Prevention," "Readiness and Management of Change," "Assessment of Best Practices," "Interventions," and "Data Tracking and Sharing." These resources are part of a larger set of available tools designed to prevent falls in hospitals.

After a successful fall-prevention pilot in three units, the 746-adult-bed hospital implemented the program in all 25 of its units plus the emergency department in 2015. By June 2016, falls with injury dropped to 12 percent of all falls, down from 19 percent the previous year, with 64 fewer instances of a fall-with-harm event. Eight units set records for their longest number of days without falls resulting in injury.

"In initially presenting the situation and then-current outcomes to leaders and staff, we used data and charts to show each unit’s number of falls, falls with injury, and contributing factors. It was very informative to depict how units were doing in comparison to each other and over time," Ms. Moore said. "The data-driven approach made it asier for unit leaders to embrace the call to action, get staff engaged, create action plans, and prioritize the improvement work."

To implement the program hospital-wide, the quality improvement team also used the AHRQ toolkit to create a fall prevention workshop for all inpatient leadership teams. The mandatory all-day training session taught unit leaders about overall quality improvement principles and fall prevention. Breakout groups brainstormed action plans for individual units that became part of the program’s strategy.

This collaborative approach has reduced falls and lowered the rate of falls resulting in injury.

"At each of our monthly leadership meetings, three or four units give progress reports on their unit’s status for fall prevention," Ms. Moore noted. "This keeps the goal of preventing falls on everyone's radar."

Ms. Moore first learned about AHRQ's resources via online research and webinars. "We regularly refer back to this toolkit as part of our daily work and continuous prevention efforts. We really appreciate the fact that all the key elements are combined into one toolkit," she said.