•  
  •  

Scholarly Commons > HCA Healthcare Journal > Vol. 7 > Iss. 5 (2026)

 

Keywords

fall prevention; fall-risk; patient safety; quality improvement; visual identification strategy; yellow gown

Disciplines

Medicine and Health Sciences

Abstract

Background

Falls, with and without harm, are monitored as a quality metric for inpatient units and are an important component of patient safety. Across the medical-surgical (Med-Surg) units at our facility, fall rates have shown some variability over time, prompting further evaluation of fall-prevention practices and opportunities for improvement. From quarter 1 (Q1) of 2022 through Q2 of 2025, several units reported fall rates ranging between 4.0 and 7.0 falls per 1000 patient days. A review of contributing factors highlighted opportunities to strengthen consistency in fall-prevention practices, enhanced education around alarm use, and improve visibility of patients at higher risk for falls.

Methods

This quality improvement initiative employed a pre- and post-intervention design within 10 adult Med-Surg treatment units. Fall rates per 1000 patient days were monitored and compared before (January 2022-June 2025) and after (July 2025-December 2025) implementation of the intervention. A multidisciplinary team of health care professionals oversaw implementation, monitoring and compliance efforts. The Yellow Fall Prevention Gown (YFPG) initiative was implemented on July 1, 2025. High-risk patients were identified and placed in YFPG for the day and reevaluated for fall-risk status every morning. Health care professionals regularly communicated high-risk designations and ensured gown compliance. There were designated treatment units within this study that were divided into pre- and post- treatment timeframes. The YFPG served as a visual cue to enhance recognition of high fall-risk patients and reinforce fall-prevention strategies.

Results

This initiative resulted in a measurable decrease in falls and fall rates over time. The fall rate per 1000 patients demonstrated a statistically significant reduction following the intervention, decreasing from 4.0 pre-intervention to 2.9 post-intervention (P < .001). Most recently, in Q4 of 2025, the fall rate was at an all-time low of 1.791. Falls and fall rates fluctuated during the initial post-intervention period before demonstrating a sustained decline over time. The YFPG intervention was associated with a reduction in falls within these Med-Surg units and may serve as a useful adjunct to existing fall-prevention practices.

Conclusion

The intervention was associated with lower fall rates during the post-intervention period. A standardized fall-risk identifying system was integrated with supportive, quantitative evidence. This model exhibits potential for consistency. Potential future work would include expanding fall-reduction strategies to other units, posted fall-risk signage and increasing education efforts to involve providers/physicians regarding bed alarms.

Download

Share

COinS