To make fall-prevention stick, we’ll pair strong team habits (briefs, huddles, SBAR) with simple measurement (run charts) and a learning system (RO-ILS). These are evidence-based tools designed for busy clinical settings.  

Every day tasks (5-7 minutes)

🗺️Quick (at the beginning of a shift, 2 minutes)

• Today’s risks (sedation, high TUGs, new starts)
• Who’s escorting whom; where are the gait belts?
• One number we’re watching (screening %, rechecks)

🔁 Huddle (mid-shift, 1–2 min)

• Any dizziness/near-falls? bottlenecks?
• Add an escort, shift a chair-with-arms, or re-route where necessary

🧾 Debrief (end, 2 min)

• 1 KEEP / 1 CHANGE for tomorrow
• Record all incidents/near misses in RO-ILS for learning (Brief–Huddle–Debrief are key Team STEPPS behaviors that reinforce communication and situational awareness.)

Crisp communication

🗣️ SBAR (60 seconds)

S: “Mr. J, week-2 RT, wobbly.”

B: “On opioids + zolpidem; dehydrated yesterday.

A: "TUG 13.8 s; orthostatics +; needs an escort."

R: “Flag High Fall-Risk, start Fall Bundle, Pharmacist med-review.” (SBAR standardizes handoffs

Displayed Measurements

📈 Run chart (1 line, updated weekly)

• Procedure: % seen within day 1–3; % re-assessed 2nd & 6th week
• Outcome: falls per 1,000 RT visits
• Balancing: added minutes per visit
• Use IHI’s basic run-chart rules (shift/trend) to detect real change.

🗓️ Rhythm

• Post the run chart every Friday
• Monday huddle = 1 min on “what changed, what we try next”; mini-PDSA (Plan-Do-Study-Act)

Learning & reporting

🧠 RO-ILS (ASTRO/AAPM)

• Report falls, near-falls, and hazards; check out a monthly “Tip of the Month”; trends shape fast fixes and policy updates.
• RO-ILS offers a secure portal and link to a federally listed Patient Safety Organization.

Mini checklists (copy for your callouts)

✅ Charge RN start-of-day

• Done—Flagged—Assign Escorts—CLEARED 10-ft TUG Lane

✅ Front desk

• Mobility aid check • Preferred language documented • SBAR dizziness

✅ RT therapists

• Verify EHR flag before treatment • Cue escort • “Chair-with-arms” ready

✅ Transport

• TUG ≥12 s/orthostatic-positive • Close the Loop on Handoff