Authors (including presenting author) :
NG CF(1), LO KP(1), CHEUNG TP(1), SO KF(1), TSANG LF(1), LEUNG LM(1)
Affiliation :
Nursing Service Division, United Christian Hospital
Keyword 1: :
Fall prevention
Keyword 6: :
Data analysis
Introduction :
Inpatient falls represent a persistent patient safety challenge with direct implications for clinical outcomes and organizational risk management. Prior to this initiative, opportunities existed to strengthen fall prevention: coordination across clinical teams could be enhanced, risk assessment protocols required greater standardization, and patients who experienced falls would benefit from systematic review to prevent recurrence. A more formalized governance structure was needed to strengthen accountability and enable data-driven quality improvement. This structured initiative established an integrated fall prevention system embedded within the hospital's clinical governance framework.
Objectives :
The primary aim was to reduce inpatient fall incidence through targeted, evidence-based interventions. Secondary objectives included enhancing multidisciplinary collaboration, standardizing risk assessment protocols, sustaining compliance with preventive measures, and embedding fall prevention within the hospital's governance structure.
Methodology :
A structured PDCA (Plan–Do–Check–Act) cycle was implemented within a multi-tiered clinical governance framework. The Plan phase involved two-tier retrospective analysis of fall data, environmental audits, and workflow assessments. The Do phase deployed interventions coordinated through the reformed Falls Assessment Clinical Team (FACT), staff awareness campaigns, e-learning modules, tailored preventive tools (restraint reference cards, enhanced rounding protocols), and clear accountability structures at ward level (ward managers, Fall Prevention Ward Coordinators) and hospital level (UCH Taskforce on Hospital Fall Prevention, Hospital Fall Prevention Ward Coordinators Meeting, FACT, Nursing Quality & Safety Subcommittee). Hospital SOPs were revised to mandate FACT referral for all fall incidents, ensuring systematic secondary prevention. The Check phase utilized KPIs, quarterly audits, and reporting through FACT to the UCH Task Force on Hospital Fall Prevention, which reported to the Hospital Quality & Safety Committee. The Act phase involved iterative protocol refinement based on audit findings, with multiple PDCA cycles planned for continuous improvement.
Result & Outcome :
Between Q1 2024 and Q2 2025, inpatient fall rates in target wards decreased by 32.8% (from 0.52 to 0.41 per quarter). Audit compliance reached 100%. Standardized risk assessment and referral to FACT were most effective for high-risk patients. The initiative strengthened clinical governance through formalized reporting mechanisms, policy embedding (mandatory FACT referral SOP), and multi-level accountability structures, demonstrating the value of systematic PDCA methodology in reducing patient harm and building sustainable governance capabilities.
