A Quality Improvement Project Aimed at Reducing Patient Falls in Ambulatory Clinics

Introduction Patient falls in ambulatory settings are uniquely challenging in that patients have more autonomy during outpatient visits and are not always easily identified as at risk for falling. Falls result in patient harm and dissatisfaction, loss of revenue, and a potential impact to the reputation of the health system. Objectives The primary objective of this study was to describe the work done to reduce falls risk for ambulatory patients. Methods This was a quality improvement project that used traditional improvement methodology to perform root cause analysis and process mapping, and to test and implement change strategies. Results The falls rate for ambulatory patients fell from 0.050 in fiscal year (FY) 2022 to 0.039 in FY23, a 22% reduction. The falls rate for ambulatory patients has continued to decrease; the current annual falls rate for FY24 is 0.030, a 37% reduction from FY21 rate 0.051, when a sentinel fall prompted root cause analysis and team focus. Conclusion While the initial intervention was only moderately successful, it led to a renewed focus on the risk of patient falls, which resulted in additional interventions and ultimately a reduction in high harm falls and the annual falls rate. Publisher’s Note This article was corrected on January 6, 2025, to reflect the authorship of Vivek N. Ahya, Ilona Lorincz, and Barbara Prior for their significant contributions to the manuscript, including their accompanying affiliations and author bios. The author bio for Rebecca Fitzpatrick and the Acknowledgments were also slightly revised. Plain Language Summary Fall prevention is a patient safety focus in many healthcare settings; however, as the first step usually involves screening to determine a patient’s fall risk, it is more difficult to identify patients at risk for a fall in an ambulatory clinic before they have been screened. After noting an increase in patient falls in its ambulatory practices in 2021—including one which resulted in patient harm—the University of Pennsylvania Health System (UPHS) set to work on reducing falls risk for ambulatory patients. The quality improvement project was piloted at an outpatient Neurology clinic that averages 6,500 patient visits each month, focused on redesigning the falls screening process and actions to take when a patient screens positive, with the goal of reducing falls by 10% from July 2021 to December 2023. Changing wellness survey screening questions to receive better information from patients and better identify their risk to avoid falls ultimately resulted in a 22% reduction in falls rate, which has continued to decrease beyond the original study period, as well as a reduction in the severity of injuries from falls.