Fall Prevention Post Anesthesia

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The projects goal was to develop a plan for the role of nurses as change agents to improve the prevention of patient falls in the Post Anesthesia Care Unit (PACU). The aim was to establish baseline knowledge and prior training regarding patient safety and fall prevention according to the post-anesthesia recovery unit protocol and educate staff on implementing strategies to reduce patient falls after surgery.


Postoperative falls are rarely considered possible complications that should be accounted for in the clinical care practice after surgery. However, there is a considerable prevalence of postoperative falls in PACU and other , such as patients’ homes. Lam et al. (2016) posit that an overall 1.6% incidence of postoperative falls is based on a review of 5 years records of . The authors observe that successful management of surgery and anesthesia does not guarantee the absence of adversities and postoperative complications. Further, they observe the scanty studies on postoperative falls and suitable strategies to curb them is due to the low incidence of such cases that could make them statically difficult to detect. Notably, the falls occur in unexpected circumstances and locations after an operation, such as caregivers, at the bedside, and during the daytime. Consequently, 30% of falls necessitate surgical attention and additional medical attention (Lam et al., 2016). Patient falls after surgery is often caused by miscommunication in the handoff from the operation room to the nurses in PACU.

Since the effects of anesthesia post-operation are still unascertained, postoperative falls might also result from the lingering neuromuscular and pharmacological blocking effects of the anesthetic. The current post-anesthesia recovery unit protocol Tool 3B, Scheduled Rounding Protocol, known as the 4 Ps or 5 Ps, requires proactive operationalization by nurses to prevent falls (Ortelli, 2018). These practices involve a mental review of the patient as well as their environment to control pain, attend to their personal needs, main a comfortable position of the patient, ensure placement of all the patients effects within reach, and prevent falls by reminding the patient to make a call in the patient needs to get out of bed.

Theoretical Framework


of change was adopted to develop a plan to develop the role of nurses in operationalizing a safer environment for to falling. Lewin identified three phases that the change agent must undertake before the planned change becomes part of the system: freezing, movement, and unfreezing (Marquis & Huston, 2020). Unfreezing involves the communication of the need for change to the operation room and PACU nurses. According to the post-anesthesia recovery unit protocol, this process involved an inquiry of the baseline knowledge and prior training regarding patient safety and fall prevention. Once the baseline knowledge level regarding patient safety and fall prevention was identified, the need to improve to meet the current recovery unit protocol was established. The second phase, movement, was initiated (Marquis & Huston, 2020). The challenges to transition plan of educating the nursing teams on best practices, such as the 5 Ps and the use of assistive monitoring technologies, were identified and addressed by setting goals, inspiring employees, setting goals, building trust within the team, and making change a priority in the team (Cuttler et al., 2017). This measure was critical to the teams attitudes, perceptions, values, and behaviors as desired for installing the new system (Ortelli, 2018). Refreezing is the final phase and involves establishing a support system for adopting the new change, such as guidance by the anesthesiologist and the Director of Nursing (DON) in the next three months.


According to the post-anesthesia recovery unit protocol Tool and the assistive technologies, adopting the best practices helped create a safer environment for the patients prone to falling. These measures ensure hourly scheduled checkups and remote patient monitoring to ensure their safety, thus preventing falls.


Multi-disciplinary education of the OR and PACU nurses on the current post-anesthesia recovery unit protocol and best practices inclusive of monitoring equipment effectively prevent post-operation falls. This change aimed to eradicate the handoff procedure errors between these teams associated with most falls. Lewins Change Theory of change was critical to align the team’s attitudes, perceptions, values, and behaviors as desired for installing the new system for fall prevention and aligning with the post-anesthesia recovery unit protocol.

team’s attitudes, perceptions, values, and behaviors


Cuttler, S., Barr-Walker, J., & Cuttler, L. (2017). Reducing medical-surgical in-patient falls and injuries with videos, icons, and alarms.BMJ Open Quality,6(2), e000119. https://doi.org/10.1136/bmjoq-2017-000119

Lam, C., Hsieh, S., Wang, J., Pan, H., Liu, X., Ho, Y., & Chen, T. (2016). Incidence and characteristic analysis of in-hospital falls after anesthesia.Perioperative Medicine,5(1). https://doi.org/10.1186/s13741-016-0038-z

Marquis, B., & Huston, C. (2020).Leadership roles and management functions in nursing(10th ed.). LWW.

Ortelli, T. (2018). AHRQ Resources for Preventing Falls in Hospitals.AJN, American Journal Of Nursing,118(5), 63-64. https://doi.org/10.1097/01.naj.0000532835.08637.c7