HEADING TOWARD ZERO: Fall Reduction – A Patient Safety Program
Grady Memorial Hospital
• Founded in 1890 and opened in 1892
• Provide medical care for the underserved residents of
the Atlanta community
• Operated by the City of Atlanta
• 1940s developed a relationship with Fulton and DeKalb
Counties
Grady Health System
• Level I Trauma Center
• Burn Center
• Comprehensive Stroke
Center
• Level III PCMH Network
• Regional Cancer Center
• Infectious Disease
Program
• 6 Neighborhood Health
Centers
• Largest LTC and Rehab
Facility in Georgia
•
Primary Training Site for Morehouse
and Emory Schools of Medicine
Grady Health System
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The largest public hospital–based health system in the Southeast,
providing more than 200 specialty and subspecialty health care
clinics
It is the safety net provider for uninsured and underinsured Atlanta
residents.
Inpatient nursing care is provided by the 1,500 professional
registered nurse staff.
The National Association of Public Hospitals has three times
recognized Grady in its First Place Safety Net Award Category.
Background
• Inpatient falls consistently account for the largest single category
of reported incidents in hospitals
• In acute care, fall incidence ranges from 2.3 to 7 falls per 1,000
patient days depending on the unit.
• Falls rank as the eighth leading cause of unintentional injury for
older Americans
• A hospital fall that results in serious injury could add at least
$19,398 to a patient’s expenses due to increased LOS and surgery.
• A multifactorial falls risk assessment and management program as
been found to be the most effective component for fall
prevention
Yates, K. M. & Creech, T. (2010)
Statement of Problem
• In adult acute care inpatients, does the use of
multifactorial falls risk management program
reduce or maintain the number of patient falls
with injury as compared to the NDNQI fall
with injury Z score?
Baseline Data
Falls with injury in 2012 was 0.28 falls with
injury per 1000 patient days, a 0.13 increase
from 2011.
The NDNQI hospital Z score 1st quarter 2012
was -0.46 compared to the NDNQI benchmark Z
score of 0.06.
The Problem: Increase in the number of
falls w/ injury
• 2011: 0.15 falls w/ injury per 1,000
patient days (n=20)
• 2012: 0.30 falls w/ injury per 1,000
patient days (n=40)
Enrolled in NDNQI, and Partnered
with GHA to participate in best
practice conferences and webinars.
Involved leadership, nursing staff, and other
interdisciplinary healthcare workers in interprofessional collaborative practice team.
Goal: Achieve/Sustain a mean Z score below national
NDNQI mean.
Hospital Board Involvement
• Provide oversight of the fall reduction patient
safety initiative; Monitor implementation
process of the fall reduction program and,
Evaluates the fall reduction program
outcomes on an annual basis
Senior Hospital Leadership
involvement
• Empower middle managers to authorize
changes in procedures as needed, Authorize
resources (staff, products, supplies, equipment)
for fall reduction initiatives, Provide financial
support to purchase equipment and supplies to
implement the fall preventive program, Remove
barriers across departments, Help reduce staff
resistance to change related to the fall
reduction program, and evaluate and provide
feedback on a quarterly basis during Quality
Goals
Medical Staff Involvement
• Review the need for specific types of
rehabilitation therapy
• Write orders for specific interventions and
activity level
• Assess and document the findings of the
physical examination in the medical record for
each patient who experiences a fall.
• Review medications for fall risk and makes
changes to medications as needed
Nursing Staff Involvement
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Utilize the Morse Fall Scale (MFS) to determine the Risk Assessment for falls for
patients seen in both the in-patient and outpatient settings.
Determine a fall risk score for every patient daily.
Initiates, updates, revises and individualizes fall prevention care plan
Implement appropriate interventions based on the documented fall risk score
using the “Fall/Injury Prevention Protocol” for inpatients
Conduct Patient Safety Rounds every 2 hours. Staff members observe the patient’s
environment for potential hazards
Conducts hourly rounding to assess for 5 Ps (potty, position, personal needs, pain
and pumps)
Educates patients and families on fall prevention strategies, use of assistive
devices, and the care plan
In the event of a fall, the patient care staff will notify the physician, report the fall
event in Peminic, and conduct a fall debriefing huddle with all staff involve to give
circumstances of the event and determine if the event was preventable or not
preventable. The debriefing serves as an opportunity to reflect on the experience
and make it meaningful by identifying what was learned by asking the “What, Why,
and How” of the fall event.
Other Hospital Personnel Involvement
Recognize patients at risk for fall and assist as
appropriate, Report potential environmental
risks to Facilities Management, and Report floor
spills to Environmental Services and/or the
manager of the area
The Team: CNO, Clinical Educators, Unit
Directors & Champions, Risk Management,
MD & Executive Leadership.
Education: Interactive presentations,
AHRQ, HEN webinars, grand rounds
monthly education.
Engagement: Fall Safety Observation
rounding, monthly meetings, practice
reviews, Nursing Staff PI Teams, Fall
debriefing s/p fall event .
Evidence-Based Interventions: Use of the universal fall
precautions, fall signage, color-coded socks and armbands, bed
alarms, nurse telephones connected to bed alarms, scheduled
hourly rounding for 5 P’s (potty, position, pumps, pain, personal
items), standardized assessment of fall risk factors using Morse Fall
Risk Scale, patient education to “Call, Don’t Fall”, care planning
interventions, and post fall procedure, including clinical reviews and
root cause analysis.
Interdisciplinary Team Activities
• Attend all meetings every 4th Monday of the month
• Monitor and review results of high risk patient with a
Morse fall score > 45
• Assist and educate on Fall Safety Observation
Inpatient Rounding,
• Complete Post Fall Debriefing reviews
• Provide annual and monthly education and Fall
Prevention
• Monitor and review results of Peminic Reporting
• Monitor and review results of fall debriefing reports
• Utilize PDSA model and develop action plans
Universal fall precautions and Patient Safety rounds measures
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Absence of Cluttered tables/stands/chairs
Call lights in reaching
Hospital bed in low position when a patient is in bed
Raise bed height to comfortable height when the patient is transferring out of bed
Night lights or supplement lights in use
No Spills/wet on floor
No Floor construction defects
No obstruction to passage ways
Absent/broken/loose, and Sturdy handrails in bathrooms and/or hallways
Beds/stretcher/exams tables’ brakes working in locked position
Wheelchair brakes working and in locked position
Rolling equipment without breaks or locks not in use by patient
No Broken furniture on unit or in patient/visitor locations
All footwear has non-skid soles/bottoms
Assistive devices (walkers, canes) have rubber tips.
Patient assessed need for assistance during elimination and staff remains with patient as needed.
Bedside commode provided if necessary. If patient is bed bound, keep clean bedpan/urinal within easy reach.
High visibility maintained: curtains, doors and blinds open when not attended
Admitted ambulatory patient oriented to environment/time/person/place at least every 4-8; as needed
Shift SBAR handoff report used at change of shift and/or caregiver, trip slip report to transporters; transporters
report to receiving department.
Patient asked about his/her toilet needs q1 from 0600 am to 2200 pm and – every2 hours from 2200 pm to 0600 am
if awake providing assistance as necessary.
Hourly rounding completed for 5 Ps (pain, potty, position, personal items, pumps)
Fall Safety Observation Inpatient Rounding Tool
Date: ___________ Unit: _________
High Fall Room: ______________________________________________
Observation Room/Bed: _____________Patient Initials: ___________
MORSE FALL SCORE:__________________________
Observation
1. Is there a Fall Risk Signage on the patient
Door?
2. Does patient have blue armband on wrist?
Y
N
Comments
3. Does patient have blue socks on feet?
4. Bed in lowest position?
5. Is bed set with fall alarm on? (HIGH FALL)
6. Does patient know how to call for assistance?
7. Side rails up? How many are up?
8. Is the patient’s bedside Call/TV control cord in
reach?
9. Is bed space clear and unobstructed?
10. Is there a bedside commode provided for
Patient, IF needed?
11. Is every one hour round form completed on
high fall patient?
12. Is Bed Computer port plugged into com-port
for Nurse call system ?
13. Patient /family Educated on Fall Risk on IPED?
14. Patient’s Care Plan is updated/Revised for Fall
Risk?
Conducted By: ______________________________ Date: __________________ Time: __________
Fax completed copy to 404-489-6415 (4-6415) attention: Falls Committee-Icopeland
Study
NDNQI data on falls with injuries over
time revealed the hospital value being
below the NDNQI benchmark Z score for
nine continuous quarters (27 months).
The NDNQI benchmark Z score ranged from
0.02 to 0.06 (mean = 0.046, median = 0.05, mode
= 0.05). The hospital Z score ranged from -0.23 to
-0.50, (mean = -0.36, median = -0.35, mode = 0.33).
The Control Chart on fall rate per 1000
patient days showed minimal variation
with upper control limit of 0.0040, lower
control limit of 0.0015 (mean = 0.0028).
Results validated that interventions using multifactorial
fall prevention practices reduced and sustained the
number of patient falls with injury as compared to the
NDNQI fall with injury Z score.
Structure Measures
• Nurses telephones programmed into nurse call
system and connected to alarm
• Bed Alarms operable,
• Color coded socks and armbands stocked in PYXIS
supply station,
• Bedside commode stored in each patient’s shower,
• Color coded Door signage for at risk and for repeated
falls mounted outside patient rooms,
• White boards mounted for identification of hourly
rounds and patient reminder to “Call, Don’t fall”.
Process Measures
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Fall risk assessments
Care Planning and Intervention
Universal Fall Precautions and Safety rounds
Post Fall Debriefing
Outcome Measures
• Inpatient fall rate per 1000 patient days
• NDNQI hospital mean Z score per 1000
patient days
• Total number of patients falls with injury .
Results
Sustained fall with injury rate below NDNQI for
9 quarters
Results
# of Patients Falls w/ Injury
50
46
45
40
38
35
30
25
20
15
13
10
10
5
0
TOTAL 2012
TOTAL 2013
1Q2014
2Q2014
Statistical Process Control Total IP
Falls per 1000 patient days
Chart 1
Inpatient Falls Rate per 1000 Patient Days
Hospital Rate
Mean
UCL
0.0045
0.0040
0.0035
0.0030
Fall Rate
0.0025
0.0020
0.0015
0.0010
0.0005
0.0000
months
LCL
Linear (Hospital Rate)
ACT
Barriers: Completion of fall debriefing forms, utilization of fall
calendar count display poster and door signage, accessibility
of properly fitted colored coded socks, continuous
communication connection of patient bed to the nurse call
system/phone, and incomplete data of fall event in incident
reporting system.
Actions Taken:
1. Gradually introduced the fall calendar count poster by getting the staff
involved and allowing flexibility on how the units will re-introduce this
best practice.
2. Added the checking of the bed connection to the patient safety rounding
checklist.
3. Re-evaluated vender product for sized colored socks.
4. Introduced a house-wide campaign on the door-mounted signs requiring
staff to complete a computer-based learning module on its usage.
Developed patient and staff education flyers on the use and indication of
the door-mounted signs.
5. Fall Debriefing forms are monitored each month and a report on missing
debriefing events are reported to the Unit Fall Champion, Unit Director,
and Chief Nursing Officer.
6. Falls are now being reported in a new reporting system which provides
automatic notification of fall events to the Unit Director, Unit-Based
Educators, Risk Management, Nurse Executives, Patient Safety
Accessibility of properly fitting of
Non-skid color coded socks:
• Process monitoring and root cause analysis identified
that one size sock designed to fit all patients was not
comfortable and well fitting for many patients.
• To resolve this barrier the Fall reduction team leader
had vendors to present an alternative to the
organizational current sock and was able to identify a
vendor who could provide non-skid sock sizes in
extra small, small, medium, large and extra-large.
• A trial was conducted and the new socks were
purchase and implemented.
Use of FALL Debriefing forms:
• Process monitoring and root cause analysis
identified non-compliance and lack of staff
understanding on completion of the form.
• Actions taken to resolve this barrier were:
development of guidelines, re-education of
staff, and escalation of non-compliance to the
CNO.
Fall Calendar Count Display poster:
• During rounding, the fall team identified
that staff was not updating the poster with
the number of days since last reported
falls.
• Actions taken to address this barrier were
assigning the charge nurse or designee
accountability and ownership to ensure
the number was updated daily.
Reporting falls in PEMINIC:
• Staff currently do not have access to add or
update to reported event in the system.
• Once staff has entered information into the
quality risk incident reporting system (Peminic),
the system did not allow staff to re-enter to
provide crucial updates, missing information and
edits.
• Actions taken to correct the barrier were: staff
re-educated to provide missing information to
Unit Directors, who have the ability and access to
update information in the system.
Updating whiteboards:
• Staff was inconsistent in referring to the patient education
prompts on Call, Don’t fall and documenting hourly rounds
of the 5 Ps (pain, potty, position, pumps, and personal
items) on the communication white board.
• Staff was re-educated to document hourly rounds and also
to reference the “Call, Don’t Fall” educational message
which is located on the communication boards
• Door Signage: There was inconsistent use of visible
communication laminated paper flyers on doors to alert
staff that patient was at risk for fall. Sometimes the
signs/flyers were posted and sometimes they were not.
• Corrective action taken was that paper Flyer signage was
discontinued and permanent door signage was mounted.
Hand-held mobile phones by staff
RNs:
• Monitoring of processes and root cause analysis revealed
that nurse hand-held phones were frequently disconnected
from the nurse call system because the beds were
disconnected by environmental Services (EVS) and the beds
were not re-connected to the telephone cable after the
terminal cleaning of the room
• When bed used for transport of the pt. off the unit, in
addition caused the hand-held phones to be disconnect
• Corrective Action: Collaboration with EVS to educate staff to
remember to keep bed connected to wall mount to make
sure the bed always communicated with the nurse call
system. Also, bed checks were added to the charge nurse
rounding check-list.
Updating Fall Prevention Care Plans:
• Data collection and monitoring revealed that
staff was not updating care plans with new
fall interventions when patient’s condition
changed.
• Staff was re-educated on when it was
required to update the interdisciplinary care
plan.
Conclusion
• The results validated that multifactorial fall
prevention interventions reduce and sustain the
number of patient falls with injury as compared
to the NDNQI fall with injury Z score.
• The multifactorial program– interdisciplinary
team; staff education, universal fall precautions,
patient involvement and leadership engagement,
make this project replicable in other essential
hospitals.
Conclusion
1. The hospital exceeded expectations and accomplished its desired
results through the process used.
2. The results have shown a sustained fall with injury rate below
NDNQI fall with injury rate for 27 months or 9 continuous quarters.
However the hospital recognizes a need to improve its efforts to
assure sustainability of desired results:
• The hospital will continue to invest in use of electronic
process and technology to monitor its processes and assist
the staff with documentation compliance.
• A pilot is in process to develop a unit specific mobility
program; this program mission is to assess all patient ability
to “Get up and Go” with fall prevention.
References
Bonueal, N. Manjos, A., Lockett, L., & Gray-Becknell, T. (2011) Best Practice Fall Prevention
Strategies; Critical Care Nursing Quarterly, April/June, 34(2), 154-158.
Ganz DA, Huang C, Saliba D, et al. (2013) Preventing falls in hospitals: a toolkit for improving quality
of care. (Prepared by RAND Corporation, Boston University School of Public Health, and
ECRI Institute under Contract No. HHSA290201000017I TO #1) Rockville, MD: Retrieved
April, 2013 from the Agency for Healthcare Research and Quality;
http://www.ahrq.gov/legacy/research/ltc/fallpxtoolkit/
Kelly , P., Vottero, B., & Christie-McAuliffee, C. (2014). Introduction to quality and safety education
for nurses core competencies. New York: Springer Publishing Company.
National Database Nursing Quality Indictors (NDNQI; American Nurses Association 2008); retrieved
from: http://www.nursingquality.org.
Oliver, D. (2009). Fall Risk prediction tools for hospital inpatients: Do they work? Nursing
Times, 105, 18-21.
Polit, D. & C Cheryl T. (2010). Nursing research – Generating and assessing evidence for
nursing Practice.9th edition. Philadelphia: Wolters Kluwer/ Lippincott Williams &
Wilkins.
Yates, K. M., & Creech, R. T. (2010). Acute care patient falls: evaluation of a revised fall
prevention program following comparative analysis of psychiatric and medical patient
falls. Applied Nursing Research, 25, (2012), 68-74. Retrieved from
http://www.elsevier.com/locate/apnr
Questions