IHI Expedition: Protecting Your Patients from Injurious Falls
Session 1 Chat Log
What is your goal in participating in this Expedition?
Maria Granzotti: reduce falls.
Tiffany Noller: Innovative prevention strategies
Marya O’Donovan: To reduce falls with injury
Lisa MacDuff: help reduce severity of falls
Pam Davis: Fall reduction
Amy Hester: Reduce overall fall rates
Jeanniline Koehler: What can we do better to reduce our fall rate?
Brandi Conner: Decreasing rate of falls and injuries from falls
Cara McCormick: learn new practices for fall prevention and engaging staff in fall prevention
Sow Chun Ng: To know innovative intervention to prevent fall
Ruth Blackwell: Learning new ideas to explore.
Donna grant: We are hoping to decrease falls with injury.
Tonya Montesinos: reduce total falls
Nannette Storr: prevent all falls with injury
Providence Alaska Medical Center: to decrease our fall rates and falls with injury!
Kelly Carter: Reduce falls overall
David Avalos: See if we have implemented all evidence-based interventions.
Dina Lipowich: Share best practice in falls and injury prevention.
Linda Barrett: Learn new, innovative ways to reduce falls with injury
Eve Woods: Decreasing falls with injury
Donna Johnson: Innovative ways to look at preventing falls in pediatrics
Romer Benitez: Prevention
Tabatha Bowers: To learn new strategies to reduce injurious falls
Teri Whiffen: Reduce injurious falls
Sherry baker: Improving fall reduction techniques, learn new ideas
Colleen Rosario: Decrease patient falls.
Mary Lowe: reduce falls and falls with injury
Robert ready: all of the above
Michael Cupples: To prevent falls with injuries
Beth Snitzer: No falls.
Chern Yih Lee: in reducing falls and injuries
Grace Chun: zero falls thru innovation
Dianne Richmond: Reduce patient falls
Carolyn Wilson: To ensure we are implementing all aspects required to reduce falls in hospital
Pamela Edwards: The goal of Tallahassee Memorial HealthCare is to create a patient centered falls
prevention program
Pamela Venglarcik: reduce falls
Patricia Lockamy: new ideas to prevent falls in the home health setting and risk assessments
Sharon Annee: to reduce falls overall
Donna Redding: Reduce overall falls and falls with injury in all nursing units
Jan Dionne: our goal is to decrease our fall rate and what is the standard around the country
Laurie Yuditsky: reduce falls with injuries
Johanna Mattiola: Learn new ways to prevent falls, particularly falls with injury
Karen Schatz: reduce fall rates and prevent injury
Judy Bridgewater: reduce falls rates in my institution
Lisa MacDuff: learn strategies
Ailen bowman: Eliminate Never Events
Richard Muphy: Reduce avoidable falls
Laurie Garrison: Reduce falls, and learn new techniques to implement
Teresa Fuller: To reduce our falls with injury
Shawna Cupples: review and revise fall management policies
Evelyn Velazquez: To get ideas to keep patients safe and free from falls.
Kevin Hunt: Acquire Best practices, reduce falls with injury, shared learning,
Carla Hall: Strategies to prevent falls with injury
Miranda Shoemaker: Reduce falls
Dru Wyatt: I am all for learning how to help patients be more safe and reduce falls.
Debra Lanclos: To decrease our fall rate.
Kyle Willey: To reduce patient falls
Diana Ellison: to learn what else we can do to protect our patients from falls and falls with injuries
Geri Towmdrow: learn new and different ways to reduce falls
Marie Blackburn: Decrease falls.
Robin - Baldwin Park, CA: Sustain fall prevention strategies in the hospital
Jennifer Baker: Reduce falls
Laura Verbanic: Decrease fall by learning new techniques
Gordon Cole: innovation in fall prevention through technology and research
Sue Ullrich: Decrease Falls with injuries throughout our organization.
Sheryl Nakanishi: Sustain low fall rates and prevent patient injuries
Toni Grant: Tools to decrease falls with injury
Diane Sanders: decrease falls
Elisabeth Rodgers: To decrease fall in our facilities.
Beth Duthie: Learn cutting edge information about falls prevention
Rebecca Beauchamp: To learn new best practices for implementation at Wake Forest Baptist.
LYNNE HOUSTON: to reduce falls in our inpatient areas
Linda Bledsoe: Efficient and Effective Fall Interventions
Chris Ann Meaney: walk away with some new meaningful intervention strategies
Joan Miller: Reduce injurious falls and identify evidence based interventions
Judith Mitchell: Reduce falls and injury in psychiatric population (adult and senior)
Dinah Junge: Reduce falls with injury
MaryLou Watson: Learn more innovative ways to decrease falls with injury
Mary Moore: I want to learn what other hospitals are doing to prevent falls so we are doing everything
in our power to decrease falls.
Patricia Johnston: To reduce patient falls in the oncology population
Judith Kraft: Safe patient population
Lisa Di Prospero: Working on a corporate initiative to prevent injuries from falls. Looking for more
information
Jovan Reyerson: Identify how to reduce toilet related falls because they are the falls with the highest
incidence of harm
Lily Ramirez: Decrease falls and compare interventions
Julie Bruce: looking for new interventions tools
Kaiser Permanente Woodland Hills: Minimize moderate to severe falls
Glenda Babineaux: Reduce falls in confused patients
Catherine Brennan: To learn strategies to decrease injurious falls and overall decrease of falls
Charlene Ladouceur: Managing and dealing with the prevention of patient falls
Kimberly Walsh: Looking to develop strategies to minimize fall risk
Ercell Roden: decreased falls and injuries in our hospital. Patient safety is at the top of our list for
improvements
Sandra Kakiuchi: Gain info on best practice interventions for falls in inpt acute care setting
Beth Radecki: learn about the new IHI tool kit
Charles Reed: Learn about best practices for implementing a falls prevention program
Kyle Willey: More group participation with prevention of falls
Leah Apatan: Learn EBP to reduce falls with injuries
Beverly Venters: Decrease # of falls
Rose Mary Carrico: get benchmarks and definitions along with increase patient safety by reducing falls
Robyn DeGennaro: decrease falls with injury -- evidence based fall prevention practice
Jan Machanis: Identify above and beyond what we already know
Celia Ryan: To reduce the fall rate from 2.72. to 1.7 by Dec. 2013.
Irene Strejc: Reduce fall occurrences and improve strategies to prevent them
Paula Gellner: Decrease overall falls and increase patient and staff engagement
Cassandra Wakeifeld: Creative ways to reduce falls with staff engagement
Vicki George: Decrease falls with injury
Beth Petty: Baylor Garland wants to reduce fall rate.
Elizabeth Zoller: learn about best practices to reduce falls
Betty Weaver: Leslie Gillies - HHS : educate ourselves regarding IHI falls prevention approach for
application into our organization
Robin - Baldwin Park, CA: Sustain fall strategies to reduce number of falls.
Debra Carnes: learn new ways to prevent falls and resulting injuries
Nicole Harrison: Memorial Hermann - Houston, TX would like to learn to reduce falls.
Mary Ann Jacobs: Decrease falls with injuries
Tee Sock Tiow: The whole team of falls prevention workgroup are onboard this virtual course
Patricia McKeon-Hoffmann: Reduce serious injuries from falls utilizing new initiatives.
Vicki George: Do you have any data on Hospice : home care & in-patient units?
Amy Cox: Do we know that hip fx in hospital falls are largely falls causing fx, or fx causing falls?
Kelly Carter: does anyone find in practice that your risk screening tools do not capture the population
that is falling?
Kelly Carter: Robert, how does your unit handle the gap?
dawn Hippensteel: ours does but we still are having falls sometimes the pt even has a one to one sitter
Gordon Cole: What screening tool do you use
Vicki George: Absolutely! Our assessment tool does not capture the hospice patient accurately.
Geri Towmdrow: we use Morse scale which has some gaps
dawn Hippensteel: Morse falls scale
Kelly Carter: Schmid Scale (may have spelled incorrectly) our population that is highest fall rate is our
40-59 year olds
Chern Yih Lee: We're using Morse scale but modified to our general setting
Geri Towmdrow: example of gap in Morse...15 points for "delirium" and 20 points for capped IV
Vicki George: We use a tool that was developed by our organization. It is not evidenced based nor
tested for validity...
Gordon Cole: We have addressed the gaps by acting on different questions within the Morse fall scale
Kelly Carter: Gordon, how do you act on the various questions?
dawn Hippensteel: we only use the 20 points for a running IV
Jan Dionne: has anyone modified the "MORSE" if so what did you change.
Geri Towmdrow: Gordon can you give me an example
Chern Yih Lee: post-surgery, risk taking behavior and medications effect was added in for ours
Jan Dionne: Gordon, any issues with copyright issues?
Lisa Clowes: did anyone catch the name of the other risk assessment tool that has been proven to
capture those at most at risk. We caught that one was the morris, but didn't catch the other one
Patricia Lockamy: stratified
Kelly Carter: Vicki, how did your organization develop a scale? Does it work?
Gordon Cole: We reduced our falls by 75% in a step down setting by triggering high risk fall precautions
for those who scored for "Forgets Limitations" regardless of total Morse score
Lisa MacDuff: stratified
Jan Dionne: stratified fall screen I believe
Vicki George: We are looking to change to the Schmidt Assessment tool which is evidenced based and
better captures hospice patients
Geri Towmdrow: Gordon..nice!
Lisa Clowes: thanks!
dawn Hippensteel: forgets limitations and medication is a huge risk especially diuretics
Kelly Carter: Gordon - was the reduction across all age groups?
Gordon Cole: Yes
Kelly Carter: wow. great job!
Jackie Beaver: Gordon - would you be willing to share your email address?
Ng sow Chun: any assessment tool specific to neurosurgical patients?
Julie Bruce: I thought changing a validated tool causes invalidation until re-validated
Jan Dionne: Julie, I thought that too
Gordon Cole: gccole@geisinger.edu
Tiffany Noller: Julie you are right. When you change a validated tool, it is no longer considered valid.
Geri Towmdrow: Isn't it revalidated by the results
Tiffany Noller: It can only be revalidated with studies
Gordon Cole: I didn't really change the tool, just added an additional trigger for action.
Tabatha Bowers: We are currently using the Schmid tool...very user friendly
Geri Towmdrow: Absolutely Gordon
Tiffany Noller: Gordon- your idea is great, and is not changing the tool. That is simply giving clinicians
the ability to critically think about their patient and make them a fall risk based on assessment.
Julie Bruce: is anyone using the John Hopkins tool? this is Leslie Kunz not Julie Bruce
Teresa Fuller: we are about to switch to the John's Hopkins tool. We trialed it, and captured more
patients as fall risk.
Julie Bruce: has it been validated yet?
Geri Towmdrow: Does anyone use video monitoring? If so are you finding it effective?
Teresa Fuller: I am not sure. But, we feel that it works better than Hendrich to capture potential fallers.
Kelly Carter: we use video monitoring in lieu of 1:1 but just began trialing it. person needs to be able to
be redirected.
Beth Snitzer: I have seen video monitoring used in some Virginia hospitals.
Geri Towmdrow: Agree. We're finding that the patients fall before we can get to them
Carla Hall: Our problem is that almost everyone is now captured at high risk, which causes nurses to
overlook those who may truly be high risk. We are looking to modify our tool as well as a result. We
threw the book at falls and falls went up.
Gordon Cole: If everyone is at risk, no one is at risk. What tool do you use?
Jan Dionne: Has anyone been trying to decrease the use of alarms?
Michael Cupples: Carla- We have the same problem here
Glenda Babineaux: who manufactures hip protectors
MARY ANN LOREN: is it enough just to ask any history of fall as screening criteria for all patients in
ambulatory care?
Vicki George: Carla- that is what is happening here...
Geri Towmdrow: We are looking at purchasing walkers with a seat on them to use in conjunction with
gait nelts to keep at each patient’s bedside
Carla Hall: Gordan - I think Morse. I am new to the Fall prevention task force as part of Lean Six Sigma
strategies.
Kelly Carter: Lean Six Sigma?
Carla Hall: Cost reduction techniques and process improvement techniques that look at individual
processes and not the whole "book"
Gordon Cole: W use Morse as well, but still do not have high risk across the board
Kelly Carter: Carla - what do you think of it as it relates to Quality of Care?
Carla Hall: It is certainly making us look at Quality of Care. We had gotten so process oriented, Quality
was decreasing. So we are trying to focus on what processes we can eliminate while focusing on Quality
of Care. Falls is just one area. We have 9 task forces set up over various issues.
Kelly Carter: sounds interesting...!
sherry baker: we are initiating a new fall prevention called care-view, a virtual bedrail-it alarms at the
desk, decreasing noise at the bedside....I will let you know the effectiveness
Carla Hall: our patients have figured out how to turn the bed alarms off! UGH
Sylvain Trepanier: Sherry what hospital are you at?
sherry baker: Jordan Valley Medical Center in Utah...
Kelly Carter: Sherry - I would be very interested to see how that works for you. We have a very large
unit and hearing bed alarms can be a challenge
Jan Dionne: do alarms give us a false sense of security , like Geri said by the time we hear the alarm the
pt. is on the floor.
Carla Hall: Our alarms ring to the nurse’s house phone, but if they are tied up with another patient and
the patient with the alarm has to wait, it can often be too late.
Tabatha Bowers: is anyone using hourly rounding as a preventative measure, and if so, how are you
finding the results?
Catherine Kantor: We are trying out the beds with alarms that trigger once the patient is sitting up
Julie Bruce: we are still not completely hardwired
Chern Yih Lee: Our policy's doing hourly round for high fall risk patient. Still trying to audit it
Jan Dionne: we use what we call purposeful rounding
sherry baker: supposedly when the patient moves past the "virtual plane" it alerts us, before they make
it all the way to the side of the bed. we also use hourly rounding and find it very effective, most of our
falls were found to be bathroom related, hourly rounding decreased that
Gordon Cole: Hourly rounds are one piece of the puzzle....
dawn Hippensteel: hourly rounding only works if it's purposeful for example we ask to take the pt to
the bathroom before they need to go
Carla Hall: We tried hourly rounding for RNs on the even hour and MA'S on the odd hour. I rounded on
our ortho floor to watch the model. My RN had 5 patients she was responsible for. She got tied up with
one needing the MA's help for 45 minutes, so other 4 patients didn't get rounded to that hour. It works
in theory, but not in reality from our trial.
dawn Hippensteel: Carla we find that as well
Jan Dionne: we do that too Dawn
Kelly Carter: Hourly rounding/purposeful rounding is in place at our facility. difficult to audit - but we are
still in process...and I agree with Dawn.
Chern Yih Lee: Dawn: What's your idea of purposeful?
Julie Bruce: I agree We use the 5 P's with our purposeful hourly rounding
Yvonne Morier: Deer Lodge Centre in Winnipeg has implemented hourly rounding recently
Renee Comeau: We have had the hourly rounding and toileting rounds added on a few of our floors and
have found it helpful and are still looking at data on it
Catherine Kantor: do you wake sleeping patients?
Yvonne Morier: no
Sarita Rhodes-Vivour: Is anyone using sitters to help prevent falls? We usually end up using the sitter
after the fall as opposed to before...
Sandra Maxfield: we have just initiated hourly rounding with the "4 Ps" pain, potty position and
perimeter check
Kelly Carter: I believe research shows that 1:1 supervision does NOT reduced falls. we've had plenty of
falls with use of 1:1
Renee Comeau: we have tried to decrease our sitters due to the costs of them. and we have had
multiple falls with sitters with the patient.
Judy Bridgewater: I would like for my institution to consider sitters but it's a hard sell - budget and all
dawn Hippensteel: I ask patients if there is a time during the night they go to the bathroom at home
Sarita Rhodes-Vivour: we have not had many falls with sitters, but we usually don’t see the need for the
sitter until after the fall occurs.
Carla Hall: Incredible question to ask, Dawn!!!
Gordon Cole: We used sitters and found our falls went up. We no longer use sitters in that capacity
sherry baker: great idea dawn, also one-to -one sitters are not the answer at our facility. we no longer
use them for that purpose
David Avalos: Our sitters are called focused observers. The just sit by the door and observe. Not allowed
to touch patient. Same as an alarm. By the time they notify a tech or nurse, patients is on the floor.
Dinah Junge: Excellent question Dawn, as most elderly patients have a set routine at home.
Sarita Rhodes-Vivour: Our sitters carry a portable phone so they can call the nurse or tech if they notice
a patient trying to get out of bed. It has helped. I am wondering how many falls we would have if we
didn’t use the sitter at all.... I’m sure there would be more.
Catherine Kantor: Even hourly rounding seems to have its faults as the patient may be asleep on that
hour round and get up 10 min.'s later only to fall I feel you must cover all basis maybe rounding with the
sitters?
Diana Ellison: accidental falls might include someone who is incontinent on the way and slipped and fell
- might be prevented with attends or pull-ups or frequent BR
Patty Schutts: CNA's perform 15q checks, and RN hourly checks.
Catherine Kantor: I work with many patients who do not realize their limits and it has to be a holistic
approach, keeping the at risk patients on a high low bed with alarms on close to the desk with toileting
rounds… not always possible on nights when there are only 3-4 nurses for 27 patients!
Sarita Rhodes-Vivour: Very true Catherine. Patients need to be educated on those limits. The more they
know, the more careful some of them will be..
Catherine Kantor: Robert that is great if they have the capacity to understand
dawn Hippensteel: yes! Robert
sherry baker: Patty, your CNA to patient ratio must be better than ours.
Catherine Kantor: I work with neuro patients and they do not understand most of the time . . .
Jan Dionne: I agree Robert, I think we need to increase education of pts. and families about their risk to
fall.
Ng sow Chun: Catherine, I work with neuro pts too
Vicki George: From reading all the comments and it seems like there are many common issues.
Interesting to see that sitters do not reduce falls.
Catherine Kantor: Ng sow how do you educate your patients who do not understand?
Ng sow Chun: we encourage family to accompany patients, but most of the time they are not able to. so
restraint is the other option
Nicole Harrison: Has anyone seen data linking nurse to patient ratios and the likelihood of falls?
dawn Hippensteel: sometimes you educate family but if you can't you just have to come up with other
solutions
Carla Hall: Key to education family members as well. They often think they can help a patient get up
because they help them at home, but in a hospital the patients’ health is usually more deteriorated. We
are focusing on family members to call for help and not try to help the patient themselves.
dawn Hippensteel: Has anyone used carefoam chairs
Sheryl Nakanishi: has anyone used "stop- call don't fall" signs in patient room/ bathroom as a simple
reminder? has it helped prevent falls?
Sarita Rhodes-Vivour: We have signs in the rooms that say 'call don’t fall' that seems to have helped a
little...
Catherine Kantor: yes, we do
Catherine Kantor: no
Julie Bruce: we use it as one of several interventions
Mary Ann Jacobs: We are also utilizing hourly rounding, but embedding it has been a challenge...
Catherine Kantor: I have had a patient with reminders on the boards, restrained and on an alarming
high low bed fall 5 times within 3 days
Renee Comeau: we have used the call don’t fall signs in English and other languages and it didn't seem
to have much of a difference but still use them in the rooms and bathrooms
Pam Davis: We are challenged with the "Desire to Do / Will to Do" where patients will get up regardless
of their instruction. We do post fall interviews and many state that they were instructed and knew what
to do but wanted to get up on their own.
Jan Dionne: Does anyone see sign fatigue around falls?
Ailen bowman: We will soon be implementing Call Don’t Fall ceiling tiles and will be happy to report at
later date
Carla Hall: We have yellow armbands, yellow gowns and yellow signs and nurses are completely yellow
fatigued!
Sheryl Nakanishi: Ailen- thank you. we are thinking of trying it.
Ailen bowman: We are also going to use Get Well Network Fall Prevention Pathway to engage pt and
family
Judy Bianco: Do you have any data on falls in the obstetrical population either antepartum or
postpartum
Sarita Rhodes-Vivour: we are also initiating yellow gowns and socks for the very high fall risk patients.
Mary Ann Jacobs: We utilize our bed alarms in call system and it is effective as long as staff are held
accountable to responsiveness
David Avalos: Has anyone prohibited personal cell phone use on the unit? When I first became a nurse,
we didn't all have cell phones. Now I go up to the units and it seems every nurse and aide is texting or
on their phone. Any studies link popularity of cell phones with increased falls?
Geri Towmdrow: Is anybody using video monitoring? What has your success been with gait belts
Sheryl Nakanishi: David- cell phones are not allowed in patient care areas at our hospital. completely
prohibited!
Carla Hall: We have no personal cell phones on the floor - they can only use house phones which are
ways equipment and staff communicates with each other. You can be disciplined for using personal cell
on your shift.
sherry baker: no cell phones on the unit
Judith Mitchell: We actually did decrease our fall rate in geriatric psychiatry unit by using sitters, so in
our patient population, it is very effective.
Mary Moore: We are in process of implementing new Call, Don't Fall signs that have both wording
(English and Spanish) and a picture and we are putting these in the rooms and in the bathrooms since
many of our falls occur during the toileting process. We are also requiring nurses and techs to give
ongoing patient/family education related to fall prevention and why the Call, Don't Fall signs are posted.
We ALSO do hourly rounding but not as "purposeful" as it should be so we are starting to hold nurses
and techs more accountable for that too. We will see... Thanks.
Renee Comeau: Judith, I would like to connect with you about your geri psych floor as we have
implemented a lot of things over the years and wonder if we could bounce ideas off of you guys and vice
versa
Deborah Kiser: Are there any Psychiatric Hospitals out here? What kind of screening or assessment tool
do you use?
Sarita Rhodes-Vivour: we are thinking about initiating a 'safety contract' that we will use for patients
who are non-compliant and even some of those who make themselves fall on purpose. We are also
thinking of giving the patients our safety goals as part of their admission kit. The nurses should review
this on admission.. Anyone done anything similar?
Judith Mitchell: to Renee, we would love to connect with you.
Chern Yih Lee: We've started something similar (contract) in Singapore, working together with the
patient and family to prevent falls
Geri Towmdrow: Kathy where are you, is your video monitoring effective?
Renee Comeau: Judith or anyone else who wants to connect my email is rcomeau@partners.org I will
try my best to get back to anyone who wants to connect
Kelly Carter: Sarita, would love to connect with you and hear more about your contract plan. sounds like
you are in a similar area/population as me.
Carla Hall: We break out our falls by area and time of day/shift and day of week, also patient age. Our
patients falling are not all elderly. They are mostly women in the 36-55 age then the 66-75 age. That
younger group is what is confusing us right now. We are also looking at the "contract" as well. Our legal
is currently telling us it won't matter - we will still buy the fall if they do fall.
Sarita Rhodes-Vivour: Sounds good Kelly.
KATHRYN KOEHNE: You'll want to make sure your Legal department is aware of any "contract" you
make with a patient - it can have implications that implicate the nurse-pt relationship.
Beverly Venters: Does anyone require PT/OT to use handoff communication tool at the end of their
therapy session?
Kathleen Langr: Memorial Quality Patient Safety
Kelly Carter: Carla, our younger pop is our problem area too. we breakdown same way as you and it is
our 40-59 yr olds that fall. our tools don’t' capture them.
Johanna Mattiola: We have a home grown screening tool, based on what we thought was most
appropriate from the other tools, we do find consistently that we are capturing 80% of all patients who
were assessed at risk that end up falling. Is this an appropriate measure?
Kelly Carter: Sarita, my email is Kelly.Carter@wfhc.org
Kathleen Langr: Geri_ Memorial Quality Patient Safety
Sarita Rhodes-Vivour: Mine is sarita.rhodes-vivour@gwu-hospital.com
Geri Towmdrow: Kathy Memorial in Colorado Springs???
Sarita Rhodes-Vivour: Chern Yih Lee, is there any way that you can send me what you guys are using for
your contract? My email is sarita.rhodes-vivour@gwu-hospital.com
Chern Yih Lee: Sarita: sure
Sheryl Nakanishi: Johanna- our PTs connect with nursing to communicate after PT sessions.
Kathleen Langr: I have only rounded on a few floors that use it. It seems to be helpful, but patients are
so quick! We recently moved one of our monitor tecks to the nurses’ station where she will be more
accessible.
Jan Dionne: This was great
Carla Hall: Awesome Chat and session!!!!!
Kelly Carter: Chern please send contract to me too :) Thanks! Kelly.Carter@wfhc.org
Sarita Rhodes-Vivour: agreed.
Eve Woods: Would love any feedback on video surveillance
Judy Bridgewater: very interesting chat session. good information
Kathleen Langr: Geri-yes.
Pam Davis: Thank you.
Geri Towmdrow: Kathy... agree that video monitoring might not be the most effective...