Hospital achieves 50% reduction in falls with huddles, better rounding

A hospital in Fargo, ND, focused on preventable falls in its cardiac telemetry unit and is seeing admirable results. After a year of effort, falls were reduced by 25% at the end of 2012, and then the hospital hit a 50% reduction barely a month later.

The reductions are the result of a comprehensive effort to address many of the issues most directly related to preventable falls, says Tina Kraft, BSN, house supervisor at Essentia Health — Fargo. Cardiac telemetry was selected for the project because it had the highest rate of falls in the hospital. The fall reduction team started by reviewing records and surveying staff members in that unit to determine who was falling and where.

“People were complaining that there weren’t enough staff on weekends and nights, and that people were falling the most at those times,” Kraft says. “But our information actually showed the complete opposite. The falls were happening with people who were alert and oriented, with the majority happening during the day.”

The team implemented more hourly rounding with a purpose, that is, specifically checking on patients to see if they might need to get up for the bathroom or for any other reason and to ask if they had all the personal belongings they might want. The goal was to keep the patients from getting out of bed on their own, Kraft says.

Two of the key strategies are training the patient on the use of the call light and conducting post-fall huddles. In addition, the fall risk level is systematically recorded and written with colored markers on white boards in the unit and included in every shift report. Below that, the nurse writes any known problems such as a missing or malfunctioning bed alarm that could affect the fall risk.

Unit managers keep track of how well the nurses conduct their hourly rounding, and those with 80% or more for confirmed hourly checks get their names placed on a high-achievers board in the unit that is decorated. But there also is a board for those whose hourly rounding is not up to par, and the staff members are encouraged to move from the bad board to the good board.

“We’ve found that holding people accountable is an important part of this,” Kraft says. “Everyone will nod their head and agree with what you want to do, but you have to hold them accountable for what they really achieve on a day-to-day basis.”

Kraft also implemented a morning huddle for three minutes to go over each patient’s diagnosis and condition, but especially how mobile the patient is and the fall risk. There also are post-fall huddles to discuss what happened and to try to narrow down the root cause. In many cases it has turned out to be that the bed alarm was not re-applied after the patient got up for some reason.

As a result of these efforts, from January to September 2012, the unit’s fall rate decreased from seven falls per 1,000 patient days to 2.4 per 1,000 patient days, Kraft says.

“We also hung a sign in the main entrance area that says ‘X number of days without a patient fall,’ and people really respond to that. It’s very visible there all the time, and people want to keep that number going,” Kraft says. “The first time we had to back up and set it to zero, it was pretty traumatic for that nurse. But we assured her it wasn’t meant as any kind of punishment. The sign holds us accountable, and it’s had a big impact.” (See information about toolkit to address patient falls, below.)


Tina Kraft, BSN, House Supervisor, Essentia Health — Fargo, Fargo, ND. Telephone: (701) 364-4354. Email:

AHRQ toolkit can help prevent patient falls in hospitals

The Agency for Healthcare Research and Quality (AHRQ) is offering an online toolkit titled “Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care” that focuses on reducing falls that occur during a patient’s hospital stay.

Nearly one million patients fall in U.S. hospitals each year, the AHRQ notes. The toolkit is organized under six major areas that address hospital readiness, program management, selection of fall prevention practices, implementation, measurement, and sustainability.

“Fall prevention programs require an interdisciplinary approach to care in order to manage a patient’s underlying fall risk factors, such as problems with walking and transfers, medication side effects, confusion, and frequent toileting needs,” the AHRQ says.

The toolkit is available online at