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.
According
to Alexander, the Woven (Wingspan one-year vascular Imaging, events and
neurologic outcomes) trial was conducted at 16 US centres. The
investigators followed 152 patients who were treated with the Wingspan
stent from the WEAVE trial, and subsequently collected data on strokes
and deaths, while follow-up imaging assessed possible reclogging of the
stent.