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P29. Implementing a Safety Huddle Process to Prevent Falls on an Addiction Medicine Unit

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P29. Implementing a Safety Huddle Process to Prevent Falls on an Addiction Medicine Unit

Learner category:

  • Novice Level
  • Intermediate Level

Learning objectives:

  • Participants will understand patient fall risks for severe alcohol withdrawal
  • Participants will understand nursing interventions to prevent falls
  • Participants will recognize importance of early and frequent nursing assessment of patients experiencing alcohol withdrawal


In 2018, severe alcohol withdrawal syndrome predominated the themes of patient fall incident narratives. By implementing a daily safety huddle which addresses alcohol withdrawal, the unit sought to decrease falls as evidenced by the monthly fall rate. The Agency for Healthcare Research and Quality estimates 700,000- 1 million people in the US fall while hospitalized yearly (Ganz et al., 2018). Alcohol detoxification presents unique fall risks, characterized by sudden onset of delirium (Mainerova et al., 2015). The Predictor of Alcohol Withdrawal Severity Scale (PAWSS) uses current clinical data to predict severe alcohol withdrawal and delirium (Maldonado et all, 2015), assisting in implementing timely interventions. Kylor, Napier, Rephann and Spence (2016) describe a nursing unit safety huddle process that served as our framework. Our safety huddle includes a unit-based score that incorporates the PAWSS assessment to identify fall-risk patients. Scores determine a set of preventative interventions nurses can initiate. Charge RNs distribute, discuss and oversee completion of the huddle each day. The tool is passed on to PM RN staff to continuously update as necessary. Since the safety huddle began in June 2019 the fall rate per 1000 patient days has trended downward. The six months pre-intervention, the overall fall rate averaged 15.8 falls per month. During the final six months of 2019 the overall fall rate averaged 9.8 falls per month. Patients in severe alcohol withdrawal present in a variety of inpatient settings, and additional strategies to assess their risk for falls can prevent costly injury from occurring.


Todd Harvey

Todd Harvey, BSN RN CARN, has been working in Addiction Medicine Nurse for over two years, and prior worked as a public health administrator of HIV prevention programs. He is currently a nurse manager on a medically managed intensive withdrawal and rehabilitation unit. Todd volunteers on the wound care team with Prevention Point Pittsburgh.

Kelly Moran

Kelly Moran, RN, has been a registered nurse on the Addiction Medicine unit at UPMC McKeesport since August 2018. This is Kelly’s first nursing job. She has a strong passion for working with this population and takes initiative to function in the role of charge nurse. her leadership in implementing the safety huddle tool has resulted in a safer unit for our patients.

Comments (2)

  1. Dennis Hagarty

    Nice job. Falls are always a problem leading to additional injury and longer length of stays, Nice job of working as a team.

  2. Todd Harvey

    Thank you, Dennis! This project has been an ongoing refinement of our practices based on what we are learning and staff feedback.

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