IHA case studies

Eliminating Falls with Injury: Our Journey to Zero Injuries from Falls


Their journey to eliminate falls with injury started last year, working towards a safety culture to reduce harm across the board. Inpatient falls was identified as an area of opportunity to eliminate harm. As a small critical access hospital, they did not have a high number of falls with injury. However, they believed there was an opportunity to prevent falls. This project was developed utilizing Lean Six Sigma tools. They analyzed all inpatient falls by time of day, patient's fall risk and reason for fall. The hospital determined that falls occurred most frequently during night shift hours, on patients that were low risk ambulating to the bathroom. They implemented interventions that had the biggest impact on fall reduction, including patient and family participation, bed alarms on every patient during night shift and mandatory call for assistance when ambulating for all patients regardless of risk score. They also eliminated wasted time and work for the nursing staff by streamlining the risk assessments. It has been over 14 months without a fall with injury.

Contact: Carrie Erlinger, Director of Quality, Risk, Safety
Phone: (618)651-2696

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state.  These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

  • Safe
  • Timely
  • Effective
  • Efficient
  • Equitable
  • Patient-centered

(The Institute of Medicine's six aims for improvement.)

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