Perioperative patients are at greater risk for falls due to anesthesia.

Seeking to decrease the OR patient fall rate, clinical nurses and leaders established a Perioperative Fall Prevention Taskforce and implemented the following interventions:

• Positioning a designated team member at the OR patient’s side at the end of the procedure
• Using two safety straps for patient positioning on the OR table and at the end of the procedure
• Reviewing whether the patient should be extubated on the OR bed or after they are transferred to their bed or stretcher with side rails up for safety

The Task Force also worked on enhancing team communication, reviewing equipment and pre-procedure safety checklists and identifying patients at greater risk as an evidence-based practice change.

The Task Force’s efforts resulted in a decrease in the OR patient fall rate per 1,000 patient days from 0.41 in January 2020 to 0 in January, February and March 2021. The OR patient fall rate per 1,000 patient days continued to be 0 in February 2022.

Staff who participated in these efforts included: Brian Lohan, BSN, RN; Kevin McLaughlin, BSN, RN; Kimberly Wheeler, DNP, RN, CNOR; Ronald Bleday, MD; Ashley Bobrek, MS, CRNA; Amanda Kelly, MS, CRNA; Sian O’Leary, DNP, RN, CRNA; and Megan Worth, MSN, RN, CNOR, CPSN

Why It’s Magnet: Magnet designation requires an example of an improved outcome associated with an evidenced-based change made by clinical nurses in alignment with the organization’s professional practice model components of collaboration, excellence, knowledge and compassion as part of the Exemplary Professional Practice component (EP1EOb) of the Magnet model.

This is one of many examples throughout the Brigham demonstrating how nurses and colleagues work together to improve patient safety. It’s who we are.