Making Care Safer:

Falls Improvement Initiative

MICAH Meeting 08/17/2018

WHY?

Falls were happening…

We completed incident reports…

We tracked…

We trended…

We educated…

However, patient’s kept falling!

Then…

March 2018

Patient fall leading to formal complaint made with DNV

Complete review of our Fall protocols (or lack thereof)

Found that we had little to nothing

Next Steps

Creation of the following

Fall Management and Prevention Policy

Post Fall Evaluation

Fall Prevention Partnership Contract

Fall Hazard Tool

Daily review of each patient and their fall assessment

Purposeful Hourly Rounding & Documentation

Falls Dashboard

Fall Hazard Tool

MHA Keystone/ECRI Falls Site Visit:

07/11/18

Tour of five clinical units

Medical/Surgical

PACU

Radiology

Emergency Department

Specialty Clinic

Observation of environments of care

Discussions with a variety of staff

Nursing

Pharmacy

Medical Assistants

Technicians

Take-A-Ways

FALLS HAPPEN!

Not all falls are preventable

Change the way we think

Replace # of days since last fall with # of assisted falls

Celebrate assisted falls

Make certain that we are there to help patients

As falls with assist go up, falls with injury should go down

Falls Intervention Program MUST be hospital-wide, not just an Inpatient initiative

Culture of Safety and Fall Prevention and Management MUST come from the top down!

Where Do We Go From Here?

Recommendations… Communication

Opportunity for improved communication at interdepartmental level, as well as facility level

Incorporate a fall risk handoff tool when patients are being moved between units

Culture

Change focus from “all falls” to preventable falls, falls with injury and falls with assist

Changing focus from risk management to a facility-wide focus with buy-in from all

Data Reviews

Education staff on all current falls

Add risk management module to EMR or alternative electronic risk management event system

Benchmark against ourselves, as national benchmarks are not unique to ERMC

Education

Provide education to all staff regarding falls, preventable falls, falls with injury and falls with assist

Educate staff on recent falls to help staff see falls as an issue

Where Do We Go From Here?

Recommendations…

Environment

Consider night lights in bathrooms for toileting at night, as well as possibly pushing bed against wall based on patient needs

Equipment

Consider purchasing floor mats, hip protectors and anti-tippers (wheelchairs) for additional safety

Falls Committee

Creation of Falls Committee, ensuring it is frontline driven

Falls Prevention

Consider addendums to current facility falls policy, as it may not be meaningful for all units

Include other units to create falls addendums/policies for their units

Individualize each patient fall plan to meet specific patient needs

Where Do We Go From Here?

Recommendations…

Falls Reduction Efforts Set unit specific falls reduction goals

Focus on celebrating falls with assist, as an injury was reduced or avoided if a staff member is there to help patient to floor

Post Fall Huddle Formal post fall huddle should be performed after every fall and include

patient

Gain knowledge and understanding of what happened and how to prevent from happening again

Purposeful Rounding Hardwire purposeful rounding utilizing 6 P’s (Person, Plan, Position,

Personal Hygiene, Pain, Presence)

Statement driven rounding – not question driven

Rounding is intentional

Toilet and Bathroom Safety Consider additional grab bar on all units

Cheers & Beers to our TEAM!

THANK YOU!

Questions?

Heather Schragg, CIC

Director, Patient Experience ǀ Quality ǀ Compliance ǀ Risk Management