IHI Expedition: Protecting Your Patients from Injurious Falls
Session 5 Chat Log
Ambur Ballance: can anyone send me any useful tips or info re: Psych unit falls?
Kelly Wilson: Can I also get any information on Psych pts & falls
Lisa Bryant: we would also like any info on inpt psych falls
Pat Quigley: We have tools for inpt psychiatry fall prevention on our VISN 8 PSCI website... Pat
Gretchen Eslick: We currently do not use a post fall huddle but a quality review record that the staff
who found or witnessed the patient who fell fill out electronically and risk reviews it; who do you involve
in the post huddles and do you use in conjunction with another reporting system. I am reluctant to ask
staff to do extra steps if it is not value added. Thanks, Gretchen.
Beth Snitzer: At post-fall huddles we include the House Supervisor (on evenings & nights), the Chair of
the Fall Prevention Team, the nurse assigned to the pt, the Patient Mobility Team & Security.
Elaine Delvo: We do a post fall huddle that involves patient, nurse, charge nurse and pca directly
involved or not involved in the fall event. This is done in paper and downloaded to our PSR system. We
use this for system wide drill-down.
Gretchen Eslick: thank you Beth and Elaine for the feedback.
Dawn Hippensteel: We do a post fall huddle that involves patient, nurse, charge nurse and pca directly
involved or not involved in the fall event as well at that time the nurse fills out the form in the electronic
record
Mary Ann Jacobs: We have a post fall huddle process that involves the staff caring for patient that
evaluates fall prevention compliance and lessons learned. Drill down is shared in an SBAR format for all
staff to learn form.
Julia Olimpia: We use a post fall assessment form. This is filled out by the RN caring for the patient. It is
sent to me (Falls Champion) and to the director of the unit. This is done in conjunction of filing an
occurrence report electronically. The post fall assessment is not part of the patient’s medical record.
Eileen Lillian: Hi Julia, would you be able to share what are the information you obtain from the RN post
fall?
Mary Ann Jacobs: We have moved our process to have the staff document directly to the event report
to improve data collection. We found that the staff had too many forms to fill out and if the event report
was completed accurately we would be better to trend data which will assist us in evaluating program
and process.
Tabatha Bowers: We found the same thing...our incident reporting is electronic, allowing the staff to file
the incident and the follow-up to be recorded in the same place. This actually better allows us to pull
reports, and we are in the process of adapting the system to incorporate some of the information we
have learned during this expedition
Mary Ann Jacobs: what are you applying for this expedition
Julia Olimpia: We include: time, place, what happened per patient and RN, anticoagulants, list of
medications the patient has been on, frequent VS and monitoring, MD notification, if head injury
involved and on anticoagulants need for head CT ordered, morse scale, what was done to prevent fall,
type of fall, what is now being done to prevent another fall, family notification. This tool gives a better
picture of what happened than our computer based occurrence report.
Simone Gordon: Julia, we have those things incorporated into our electronic report but we also do a
paper report to answer some more specific questions such as what did you do to prevent this patient's
fall.
Glenda Totten: Are there Spanish versions for the STEADI informational brochures?
Glenda Totten: Are there Spanish versions for the STEADI informational brochures?
Tabatha Bowers: We've deleted the paper version related to falls....our electronic reporting captures
contributing factors, degree of injury, etc. ALL reports also go to our Risk Management department and
the chair of the Falls Prevention and Least Restraint committee. We actually have found that our
information is more thorough electronically. We are however going to be updating our system to better
capture falls types....
Dawn Hippensteel: Thanks for the info I didn't know the CDC had updated their falls information
Pat Quigley: Hi.. Glenda, I am not sure if there are Spanish versions of STEADI... Would have to search
the site. Pat
Glenda Totten: Thanks Pat! We can research the CDC STEADI site as well. Thanks so much for sharing
your expertise and the wealth of educational resources.
Carol Dodson: Are any of today’s participants members of stand up for Patient Safety? If so have you
found value in the Ask Me material? Thanks
Amanda Potter: Some of the patient materials do have Spanish versions available.
Chris Ashdown: You mentioned falls prevention strategies specific to patients with cognitive problems.
Can you elaborate?
Russell Stowers: Spanish version is available on many of the CDC educational materials
Sandy Maxfield: We have just implemented the Ask Me 3 in reference to safe discharge needs. Simple
for staff to use and opens doors for patients to ask not only nursing but physicians questions of all sorts.