Steady Steps Forward: Preventing Inpatient and ED Falls

Overview

St. Francis Medical Center demonstrated how falls prevention is strengthened when teams combine visibility, mobility, frontline ownership, and continuous learning. Participants observed a thoughtful, evolving approach that emphasized transparency, interdisciplinary collaboration, and layered prevention strategies rather than relying on a single intervention.

Wise Practices Shared

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What We Saw

Participants observed:

• Tier 1 safety huddles and assignment zoning
• Mobility-focused care and individualized approaches
• Real-time communication of patient risk
• Visible safety work through huddle boards, audits, and visual cues
• Continuous adaptation based on staff feedback and event learning

Key Themes

• Keep safety visible and actionable
• Layer interventions rather than relying on one solution
• Create shared ownership across disciplines
• Balance mobility, dignity, and fall prevention
• Learn openly from challenges and successes

Participant Reflection

"There's not one piece that fixes it... you have to keep layering everything together."