Reduce the number and severity of falls in hospitals in the region through the implementation of structured post-fall debriefs to identify root causes, create standardized interventions, and shared learnings across the region.

MSPC invites up to 15 hospital adult inpatient units to participate in this initiative; each interested hospital should select one unit to participate based on the criteria listed below. We welcome 1-3 debrief leaders from each participating unit. 

Each hospital is encouraged to identify an adult inpatient unit that would benefit most from focused efforts to reduce falls, based on data or a demonstrated need for improvement.  

• Units excluded from the initiative include pediatrics, L&D, mother/baby, emergency department, perioperative units, and other procedural areas. 
• The unit should have a culture of safety and engaged staff willing to actively participate in the improvement initiative.  
• The unit must have leadership support for participation from unit manager and PSO or Quality Director 

• The initiative will begin in January 2025. Site champions will participate in MPSC-led focus groups to assess the current state of falls debriefs, which will help tailor the programming for the duration of the initiative. The site champions will undergo debrief training in April, then will be expected to implement post-fall debriefs in the following months. For the duration of the 18-month collaborative, MPSC will facilitate monthly meetings for site champions focused on education, mentoring and data review. 

MPSC’s Ask of Participating Units:

• Share any existing fall policies, fall risk assessment tools, and fall debrief tool(s) with MPSC for shared learning and collaboration
• Share baseline and ongoing falls data including number of falls per month and number of falls with debrief for the duration of the initiative 
• Share identified root causes of falls and opportunities for sharing interventions across the region