Does the Implementation of Safety Huddles Reduce Falls With Injury on an Inpatient Stroke Rehabilitation Unit?

 The correct way to prevent falls is 100% recovery! AND YOUR PROFESSORS DON'T KNOW THAT! More dead wood that needs to be fired!

Does the Implementation of Safety Huddles Reduce Falls With Injury on an Inpatient Stroke Rehabilitation Unit?

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Does the implementation of safety huddles reduce falls with injury on an inpatient stroke

rehabilitation unit?

Martha Rafferty, DNP, MSN, RN

Dr. Debra Blyth-Wilk, DNP, JD, RN

Dr. Emily Sheff, PhD, RN, FNP-BC

April 6, 2025

Abstract

Problem Statement: In post-stroke patients admitted to the stroke rehabilitation unit, do daily

shift safety huddles reduce the number of patient falls when compared to no intervention?

Aim: To enhance the quality of care provided for post-stroke patients and to minimize their risk

of harm through implementing daily shift safety huddles, improving team communication and

alerting care providers to those patients at risk for falls using the Morse Fall Risk Assessment as

the guide.

Background: The implementation of daily safety huddles was borne out of the 1999 Institute of

Medicine’s (IOM) report, To err is human, where it is identified that nearly 98,000 patients die

per year from medical errors which could likely be prevented (Donaldson, et al, 2000). “Huddles

increase individual and collective accountability for patient safety, designate a fixed time during

the workday or shift to focus on care coordination, facilitate immediate face-to-face clarification

of issues, result in fewer interruptions during the rest of the workday, and foster a culture of

empowerment and collaboration in healthcare teams” (Shaikh, 2020).

Design: Exploratory descriptive interventional pilot study.

Data Sources: Patient identified inclusion criteria (admitting diagnosis of post-stroke, and

Morse fall risk assessment score of 55 or greater); safety huddle attendance sheets, falls with

injury data reported to National Database of Nursing Quality Indicators (NDNQI).

Method: Falls with injury data was assessed pre-implementation of safety huddles and during

implementation of safety huddles. Both occurrence and attendance at safety huddle was

analyzed using a Pearson Chi-Square Test, a Pearson Correlation Coefficient Chi-Square Test,

and a multiple regression three-way ANOVA test. These tests were conducted using IBM SPSS

Version 23.

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Results: There was no statistically significant association between huddles and falls. There was

a significantly significant difference demonstrated in RN attendance at huddles and PCA

attendance at huddles with a correlation showing that PCA attendance at huddles was higher than

RN attendance at huddle.