PURPOSE: The objective of this study was to identify gaps in and to improve the falls prevention strategy (FPS) of an inpatient rehabilitation facility (IRF) in Toronto, Canada.
DESIGN: A modified version of the Stanford Biodesign Methodology was used.
METHODS: Chart reviews, a focus group (n = 8), and semistructured interviews (n = 8) were conducted to evaluate the FPS.
FINDINGS: Admission Functional Independence Measure score, age, and gender significantly correlated with risk for a fall. The tool used at this IRF was not effectively capturing patients who were at high risk for falls. All healthcare providers interviewed were knowledgeable of fall risks; however, a patient's fall risk status was rarely discussed as a team.
CONCLUSIONS: The findings informed recommendations to improve the overall FPS at this IRF. CLINICAL RELEVANCE: Staff may require more coaching for implementing preventative measures/ensuring accountability and evaluating whether current strategies work. These insights can guide improvement initiatives at similar facilities elsewhere.