Falls with Injury on a Pediatric Medical-Surgical Unit
A 14-bed pediatric medical-surgical unit has had three falls with injury in 8 weeks. Two involved children ages 9 and 12 who received opioids and antiepileptic medications; one involved a 13-year-old after appendectomy. Chart audit shows fall-risk reassessment was missing after medication changes in all three cases. The current fall-risk tool was adapted from an adult tool and does not include child-specific items such as developmental level, parent presence, or toileting assistance. Bed alarms were available but not in use for two of the patients. Staff education on falls was completed 6 months ago. The unit manager asks the clinical nurse leader for a quality improvement plan.
1. How should the team interpret these data, and what quality improvement approach fits this situation?
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Three falls are a small number but a meaningful pattern: all had medication changes, two had sedating medications, and all lacked reassessment. This suggests a process failure, not simply careless staff. The adult-derived tool may miss pediatric risk, and education alone 6 months ago has not sustained practice. Use a Plan-Do-Study-Act approach with a fishbone diagram to examine patient, medication, environment, equipment, and communication factors. Start with small tests on one shift or one hallway rather than a unit-wide mandate. Include frontline nurses, pharmacy, child life, and families in designing the change. Track falls per 1,000 patient days and process measures, not just blame individuals.
2. Propose an intervention bundle and the measures you would use to evaluate it.
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Bundle: (1) reassess fall risk within 1 hour after any opioid, benzodiazepine, or antiepileptic dose and after surgery; (2) use bed alarms and visible risk signage for high-risk children; (3) hourly rounding with proactive toileting, call light, water, and parent engagement; (4) pediatric-specific risk items for developmental level, IV lines, and parent presence; (5) handoff script that names the risk and the plan. Measures: outcome - falls with injury per 1,000 patient days; process - percentage of post-medication reassessments completed and bed alarms in use; balancing - alarm fatigue and nurse workload. Review data monthly and test one change at a time.
3. How would you engage staff and sustain the improvement?
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Share the audit data transparently without naming individuals. Recruit bedside champions from each shift, ask them to co-design the reassessment workflow, and test it for 2 weeks before hardwiring. Use daily safety huddles to review high-risk patients and weekly run charts to show progress. Address real barriers such as alarm fatigue, documentation burden, and parent anxiety. Celebrate small wins and revise the tool based on staff feedback. Sustainability requires embedding the reassessment into the medication administration workflow, orienting new staff, and auditing monthly with feedback - not repeating a one-time education session.