Since the Institute of Medicine released To Err is Human: Building Safer Heath Systems (IOM, 2000), patient safety has become of paramount importance to many hospitals and national quality organizations. According to the Institute for Healthcare Improvement (IHI), patient falls are one of the most common occurrences reported in hospitals (IHI, 2010). In 2005, the Joint Commission’s National Patient Safety Goals for Hospitals added an initiative to reduce the risk of patient harm resulting from falls (Geller & Guzman, 2005). In October 2008, the Centers for Medicare and Medicaid Services (CMS) discontinued reimbursement for eight hospital-acquired conditions; costs related to patient injuries from falls are no longer paid (CMS, 2007). This national focus on reducing patient falls has engendered a climate of change in individual hospitals and health systems.

In the spring of 2007, the CHRISTUS Health Chief Nurse Executive (CNE) Council met to determine how best practices could be implemented throughout the CHRISTUS Health System. As a result, the CHRISTUS Health Evidence-Based Advisory Council was established, with one nursing director from each of the system’s regions serving on the council. Due in part to the prevalence of falls throughout the CHRISTUS Health System, developing a fall prevention protocol became the focus of the Evidence-Based Advisory Council’s first face-to-face meeting in July 2007. Over the next several months the Council met bi-weekly via teleconference to conduct literature searches, summarize the evidence, and translate the evidence into a universally applicable protocol that could be implemented system-wide to reduce patient falls and associated costs. An initial goal was set for each CHRISTUS Health hospital to achieve at least an 8% reduction in the raw number of falls from the previous year. As part of the CHRISTUS Health System, the CHRISTUS
St. Michael (CSM) nursing units (see Figures 1 and 2) embraced the system-wide fall reduction initiative.

In the spring of 2008, the orthopedic unit at CSM, along with two other units in CHRISTUS Health hospitals, began piloting the newly developed protocol. Nursing staff on the pilot units were educated about the protocol through online modules. With input from the pilot units, the protocol was revised and tailored to each hospital’s needs while maintaining the integrity of the protocol’s evidence-based practices. Following the three-month pilot, the falls prevention protocol was rolled out to all inpatient nursing units at CSM. Every CSM associate completed the online educational
module entitled Falls Prevention Protocol and the Management of the Patient at Risk for Falls.