| Primary Author: | Carol Bell, RN |
| Organization | Thomas Hospital, Infirmary Health System |
Abstract
Purpose
A Patient Fall Prevention Team, led by the Patient Safety Officer, had been focusing on reducing patient falls since 2008. Gradual improvement was noted by utilizing the evidence based practices of assessing a patient’s fall risk, identifying high fall risk patients, purposeful rounding and using bed alarms and low beds when indicated.(Morse, 2009). The team expanded their literature search to include Patient Safety and incorporated some evidence based principles.(Arford, 2005; Leonard et al, 2001; Lewis,A, 2009).
Background
Patient falls continue to be a leading adverse event and cause for patient harm. Preventing patient falls and injury is considered a nursing sensitive outcome indicator by the American Nurses Association.(Duncan et al, 2011). Hospitals continue to be challenged to implement an effective fall prevention program especially since the Centers for Medicare and Medicaid have reduced their reimbursement on patients suffering injury resulting from a fall.(NQF, 2009).
Materials & Methods
The hospital’s quality improvement model was revised in late 2010 from the traditional Plan-Do-Check-Act framework to a Plan-Brief-Execute-Debrief model.(Geary, 2012) This new approach incorporates the recommended patient safety practices of communication and teamwork in the framework of process improvement. The Fall Prevention team implemented a “patient fall debrief” in January 2011. The debrief occurs after any patient fall and includes having all members of the patient’s care team gather to discuss contributing causes and identify “Lessons Learned” to share with other units.
Results
Both the fall rate and injury from falls have decreased annually. The number of falls decreased from 122 in 2008 to 83 in 2011 with the overall fall rate improving to 1.1% from 1.7%. With the implementation of fall debriefs there has been a 70% decrease in major injuries from falls in 2011 compared to 2010. These debriefs have improved both teamwork and communication among unit staff as well.
Conclusion
Fall prevention programs can benefit by using evidence based practices from the Patient Safety literature including effective communication and building teamwork.
Bibliography
Arford (2005) “Nurse Physician Communication: An Organization Axxountability”. Nursing Economic, 23:72-77.
Duncan,J., Montaivo, I., Dunton,N. (2011) NDNQI Case Studies In Nursing Quality Improvement. Silver Springs, Maryland: American Nurses Association.
Geary,M. (publication projected summer, 2012)”Quality Improvement Science”. Evidence-Based Practice: An Integrative Approach to Research, Administration and Practice by Roussel, Taylor, Overholts & Hall. Jones and Bartlett.
Leonard,M., Frankel,A, Simmonds,T and Vega, K (2004). Achieving Safety and Reliable Healthcare. Chicago: Health Administration Press
Lewis, Anne (2009).”Teamwork: Crew Resource Management in a Community Hospital”. Journal for Healthcare Quality, 31:14-18.
Morse, Janice (2009). Preventing Patient Falls, 2nd Edition. New York, NY:Springer Publishing Company
National Quality Forum (2009). Safe Practices for Better Healthcare- 2009 Update: A consensus report. Washington D.C.: National Quality Forum.
© Improvement Science Research Network, 2012
The ISRN published this as received and with permission from the author(s).