Historically, inpatient fall prevention has focused on adults and has not been associated with pediatric patients. However, inpatient pediatric falls account for a significant number of reported hospital adverse events and contribute to increased length of stay, cost, morbidity/mortality and decreased patient/family satisfaction. One challenge with pediatric fall prevention is that pediatric patients have a broad spectrum of ages and developmental abilities.
Due to increased fall events, the Pediatric Intensive Care Unit (PICU) formed a Pediatric Fall Committee at the end of fiscal year 2023. The committee, overseen by pediatric nursing leadership and clinical nurses from the unit, aimed to raise awareness of pediatric fall prevention and engage staff in fall prevention interventions.
The committee identified opportunities for improvement by reviewing adverse event data and auditing fall documentation and bedside interventions. As a result, the committee developed and implemented “Pediatric Fall Fair” sessions. Registered nurses and assistive personnel attended these sessions during the fiscal year 2024. The educational and knowledge-building sessions included a fall risk assessment tool case study, bed alarm, chair alarm, and gait belt competencies.
The Pediatric Fall Fair provided a valuable learning opportunity for the staff and the committee. Feedback from the staff indicated that many fall incidents occurred within the first 24 hours of admission/transfer, often with parents/caregivers present. This newfound understanding led to the “No One Walks Alone” initiative, where the clinical nurse evaluates each patient’s fall risk and ambulation assistance needs upon admission or transfer. Patients and their families receive education and anticipatory guidance about the importance of having a nurse/assistive personnel present during ambulation. Patient room communication whiteboards and the electronic medical record are now updated with the patient’s fall risk and ambulation assistance needs. The committee discusses topics from the Pediatric Fall Fair with new staff, audits documentation and the bedside fall interventions, and reviews fall events at monthly meetings to highlight essential learnings.
The Pediatric Fall Committee is a change agent that demonstrates teamwork and highlights the importance of patient quality and safety. Under its leadership, the PICU team reduced patient falls from 5 in fiscal year 2023 to 1 in fiscal year 2024 by raising awareness and implementing fall prevention risk screenings and best practice interventions.