A Quality Improvement Project Aimed at Reducing Patient Falls in Ambulatory Clinics

Abstract

Introduction Patient falls in ambulatory settings are uniquely challenging in that patients have more autonomy during outpatient visits and are not always easily identified as at risk for falling. Falls result in patient harm and dissatisfaction, loss of revenue, and a potential impact to the reputation of the health system. Objectives The primary objective of this study was to describe the work done to reduce falls risk for ambulatory patients. Methods This was a quality improvement project that used traditional improvement methodology to perform root cause analysis and process mapping, and to test and implement change strategies. Results The falls rate for ambulatory patients fell from 0.050 in fiscal year (FY) 2022 to 0.039 in FY23, a 22% reduction. The falls rate for ambulatory patients has continued to decrease; the current annual falls rate for FY24 is 0.030, a 37% reduction from FY21 rate 0.051, when a sentinel fall prompted root cause analysis and team focus. Conclusion While the initial intervention was only moderately successful, it led to a renewed focus on the risk of patient falls, which resulted in additional interventions and ultimately a reduction in high harm falls and the annual falls rate.