Table 2

Second PDSA cycle (August 2021)

  • To continue with the first intervention (used in the first PDSA cycle) and in addition planned for the following

  • To pay more attention to patients at high risk of fall by introducing a ‘high-risk package’ interventions (table 4)

Rationale—The time duration for first change idea was just 1 month so we wanted to give it some more time.
The review of July data revealed that no specific fall measures were followed for high risk patients.
QI team
  • Proper use of fall risk assessment tool (Humpty Dumpty chart), risk categorisation and fall prevention advices were continued.

  • Staffs were familiarised with ‘high risk of fall’ package and it was implemented.

QI team members and Ward staffs
  • The fall incident rate for August was studied

  • Proper and correct use of Humpty Dumpty fall scale for all admitted patients and use of ‘high risk of fall package’ for high risk patients brought down the fall rate by about 28% from the baseline.

  • Despite a decline in the fall rate there were few challenges encountered in implementation of ‘high-risk fall package’ (our ward did not have enough beds with side rails)

Remarks: Lack of enough beds with side rails was a challenge which this QI project had difficulty in addressingQI team
  • Meeting of the QI members for way forward.

  • With almost 28% reduction in fall rate from the baseline, we planned to carry forward the above new ideas for the month of September

QI teams
  • QI, quality improvement.