Using a Practice Improvement Model to Reduce Falls and Harm From Falls

Primary Author:	Denise J. Mazzapica, BSN, RN-BC
Co-Principal Investigators/Collaborators:	Lynn Johnson, Jayne O’Leary, Myrta Rabinowitz, Lily Thomas
Organization:	North Shore LIJ Health System

Abstract

Background

The prevention of falls and harm from falls continues to be a challenge. All in-patient falls are deemed preventable and classified as adverse events. Falls are the most frequently reported adverse event in the in-patient setting. Falls increase morbidity, mortality, and length of stay. The Center for Medicare and Medicaid Services has placed falls on the list of eleven hospital acquired conditions.

Purpose

The purpose of this improvement initiative was to use evidence-based strategies and best practices to reduce falls and harm from falls by implementing four improvements: a) improving data quality by standardizing definitions, data collection, analysis, and reporting, b) standardizing and simplifying the fall risk assessment, c) stratify interventions to the fall risk assessment, and d) using organizational processes to augment clinical processes.

Materials & Methods

Seven hospitals, both tertiary and community settings, volunteered to be part of the improvement project. The IHI Improvement Methodology was used. Three PDSA cycles of change lasting a total of nine weeks were completed. A Fall Reduction Toolkit was developed that included a new fall risk and harm assessment tool and intervention form, standardized definitions and data analysis methods, three levels of fall and harm from falls reduction interventions based on risk, TeamSTEPPS tools to augment the clinical process change, an educational module for the staff, forms and templates to track the improvement process change, and the education completed.

Results

All of the units that participated in the improvement project pilot decreased the fall index rate and six out of seven units decreased the falls with injury rate.

Conclusion

The goals of simplifying falls assessment, stratifying interventions based on risk and patient needs, standardizing definitions, data collection and reporting were achieved. The Falls Reduction Improvement Initiative was a success and will be spread throughout the North Shore LIJ Health System.

Bibliography

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