6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial.
Approach to Improving Safety
Setting of Care
Falls in hospitalized patients are a common source of preventable harm, and the incident is considered a never event when it results in serious injury. Conducted at six Australian hospitals, this cluster randomized controlled trial sought to evaluate the effectiveness of a bundled intervention on the incidence of falls on adult wards. The bundle included assessing patients' risk for falling along with several widely used tactics to prevent falls. Despite successful implementation of the fall prevention bundle, falls occurred just as frequently on intervention wards as control wards. This study is an important example of the need to rigorously evaluate safety interventions, even those that have high face validity. The authors conclude that since these interventions appear ineffective. Organizations should consider disinvestment in these practices because completing ineffective interventions consumes a significant amount of staff time and effort. A WebM&M commentary discussed a case involving a fall resulting in injury.