Authors: (including presenting author): :
Fung SY(1), Lee WY(1)
Affiliation: :
(1)Orthopaedic & Traumatology, North District Hospital
Keyword 2: :
Fall Prevention
Keyword 3: :
Patient Safety
Introduction: :
Patient falls represent a critical patient safety issue, leading to serious injuries, increased healthcare costs and reduced quality of care. In 2023, NDH documented 82 fall incidents, with 7 resulting in serious injury (SI>4). Analysis revealed that most falls involved sound-minded (73%), ambulatory patients (51%, MFAC>5), primarily occurring at bedside (67%), toilets (22%) due to sudden lower limb weakness (63%) and balance impairment (35%).
To address this, a Continuous Quality Improvement (CQI) initiative using the Plan-Do-Check-Act (PDCA) cycle was piloted in O&T Department (Ward 2D) from 1/2024 to 3/2024, achieving a 66.6% reduction in falls. Following this success and with funding from the NTEC QOCP, the Fall Prevention Enhancement Program 2024/25 was launched hospital-wide in August 2024. This report outlines the program's multidisciplinary approach to systematically improve patient safety.
Objectives: :
The program aimed to:
1.Reduce fall rate and severity among sound-minded, ambulatory inpatients (MFAC > 5) by 30%.
2.Enhance fall prevention awareness among both healthcare staff and patients/caregivers.
Methodology: :
The program was implemented using the four-phase PDCA cycle: 1. Plan:
A multidisciplinary workgroup analyzed fall incident data to identify root causes and define the objectives above. A detailed action plan was formulated, focusing on education, environment, and training. 2. Do: Strategies Implemented
Patient & Family Education (Hospital Level):
• Developed a new Fall Prevention Educational video and posters with QR codes for easy access.
• Collaborated with the Physiotherapy Department to create warm-up exercise videos targeting lower limb strength and balance.
• Utilized the TEMI system to broadcast fall prevention reminders during visiting hours.
Staff Training & Development (Hospital Level):
• Conducted workshops on fall prevention strategies and proper use of assistive devices.
• Held ad-hoc sessions for incident debriefing and root cause analysis to foster a culture of learning.
Program Monitoring (Hospital Level):
• Established periodic review mechanisms to identify issues early, enhance teamwork, and ensure accountability.
Environmental Enhancements (Ward Level):
• Installed infrared sensors in toilets to alert staff and remind patients of fall risk.
• Added grab bars to wash basins in patient toilets.
• Implemented motion-sensing night lights at bedsides to improve nighttime visibility. 3. Check: Evaluation & Results
An evaluation in June 2025 assessed the program's impact through surveys and fall rate analysis.
Stakeholder Satisfaction:
• 773 surveys were completed (535 staff, 238 patients). High agreement was recorded on the program's effectiveness in raising awareness and preventing falls (Staff: 86%, Patients: 89%).
• Overall satisfaction with the measures was also high (Staff: 93%, Patients: 94%). 4. Act: Future Enhancement—All-Round Monitoring System
To transition from a reactive to a proactive model, the program will pilot advanced technologies for early risk identification and real-time response:
• LUNA 360: An AI-based 3D tracking system using eye-safe laser radar for precise, privacy-protecting motion tracking and behavior analysis in patient areas, even in complete darkness.
•Robotic Cat: A bedside AI companion using thermal sensors (no cameras) to provide voice prompts, movement alerts, and medication reminders while ensuring patient privacy.
Result & Outcome: :
Fall Rate Performance:
• From August 2024 to July 2025, a 42.5% reduction in total fall incidents was observed compared to the same period the previous year (Aug 2023-Jul 2024 vs. Aug 2024-Jul 2025).
• Falls among the target group (sound-minded patients with MFAC>5) decreased by 47%.
• According to the HO NSD 2024/25 NQI report, NDH's fall rate (0.23) was notably lower than the Group 1 hospital average (0.35) for the period 2Q24 to 1Q25.
