Abstract
Performing post-fall debriefing improves patient outcomes through learning from defects and addresses adherence to fall prevention programs. While addressing an increase in fall rates, a quality improvement team discovered there was no standardized tool or process for completing post-fall debriefing. The team used the Plan-Do-Study-Act (PDSA) process to improve the post-fall debrief tool, with an analysis of pilot using the implementation science RE-AIM framework. Three units with a high focus on falls and an established debriefing culture participated in pilot to generate and standardize a post-fall debrief tool. Through 2 revisions with end user and champion feedback, the tool was refined to assess any contributing factors to the fall. Through use of the PDSA cycle, the team established content validity of the post-fall debrief tool. This tool is appropriate for inpatient adult and pediatric scale-up and complementary to current fall risk assessment tools.
Published Version
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