| Principal Investigator: | Judith Moran, RN, DNSc, NE-BC |
| Organization: | Huntington Hospital |
Abstract
Problem
Falls are the most common adverse event reported in acute care facilities. Of those who fall, 20–30% suffer moderate to severe injuries, which increase morbidity, mortality and the cost of hospitalization. The Joint Commission’s National Patient Safety Goal # 9 is “reduce the risk of patient harm resulting from falls”. CMS and private insurance provides restrict financial reimbursement to hospitals when patients fall and sustain injuries. “Falls with injuries” is considered a nurse sensitive indicator of the quality of care received by patients. Therefore, it is imperative for direct care nurses to implement cost effective, evidence-based nursing strategies to decrease the prevalence of patient falls and fall-related injuries.
Evidence
Findings from recent nursing research studies have identified a relationship between nursing “best practices” and decreased patient falls, such as: RNs performing change of shift “hand-off report” at the bedside, hourly point of care patient rounds, the use of bed and chair alarms, and the development of policies/procedures regarding response to call bells. Nevertheless, little research has been conducted on the change in culture that is necessary on clinical units in order to hard wire these evidence based nursing practices into daily routines.
Strategy
The patient fall rate in a Magnet-designated community hospital was consistently below the NDNQI national benchmark. Nevertheless, nursing education was provided regarding the need to decrease patients falls in order to prevent fall related injuries and EBP nursing strategies to safeguard hospitalized patients. Reductions in fall rates were observed, but opportunities for additional improvements were identified on several clinical units.
Practice Change
In 2008, the Nurse Manager on a medical-surgical unit in a Magnet- designated hospital became intrigued with the concept of public reporting of quality data. She decided to post a dry erase board at the nursing station and list the number of “Fall Free Days” on her unit.
Evaluation
In the year following the initiation of the “Falls Free Day” strategy patient falls decreased 20% and no fall-related injuries were sustained. As many as 100 days occurred with a patient fall. This innovative best practice has become daily practice and a central focus of communication during change of shift Team STEPPS “briefs”, “huddles” and “debriefs” on the unit. The “Fall Free Days” strategy serves as a catalyst which inspires nursing staff to utilize evidence-based fall reduction nursing activities.
Results
Reporting of “Fall Free Days” at the nursing station has become a transparent way of reporting quality patient care data on all of the nursing care units at the hospital. Over 70% of the clinical units have achieved a 20% reduction in patient falls since adopting this best practice strategy.
Recommendations
The use of public reporting of quality data via transparent processes needs to be expanded in the hospital setting.
Lessons Learned
Quality data can be utilized to educate staff, patients and families regarding evidence-based “best practices” that lead to better outcomes for hospitalized patients. Improved outcomes are a reflection of teamwork, competency, accountability and pride in performance.