Journal of nursing care quality
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Multicenter Study
Reducing serious injury from falls in two veterans' hospital medical-surgical units.
A large veteran's hospital participated in a year-long collaborative project across 9 hospitals to reduce serious injury from falls in acute care, targeting medical-surgical units. The primary objective of this project was to develop and test a set of interventions (bundles) to prevent serious physical injury (fractures and hemorrhagic bleeds) from patient falls. The interventions were implemented using tests of change on 2 medical-surgical units focused on engaging unit-based staff and combining innovations for vulnerable populations at greatest risk for injury if they fall.
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Healthcare systems are recognizing "human factor" flaws that result in adverse outcomes. Nurses work around system failures, although increasing healthcare complexity makes this harder to do without risk of error. ⋯ We describe how reliability principles were used to teach nurses to improve patient safety at the front line of care. Outcomes include safety-oriented, teamwork communication competency; reflections on safety culture and clinical leadership are discussed.