FALL PREVENTION COMPARE AND CONTRAST SELECT HOSPITALS

MICAH FALLS WITH INJURY

2017 - .89 falls per 1000 patients

2018 - .76 falls per 1000 patients

WE’RE ALL DOING IT

• Universal Fall Precautions

• Bed low and locked

• Partial side rails up

• W/C wheels locked

• Non-slip footwear

• Clean and dry surfaces

• Uncluttered areas

• Orientation to surroundings

• Call light education

• Personal item within reach

• Appropriate lighting

• Encourage use of sensory and

ambulatory items

• Handrails in bathroom

WE’RE ALL DOING IT

• Risk assessment upon admission

• Ongoing risk assessment throughout visit

• Risk Categories (High, Moderate, Low)

• Educate patient and family of risk and

interventions

• Identifiers on doorway and wristbands

• Environmental factors (clutter, dry floors,

lighting)

• Communication of fall risk across shifts

and departments

FALL RISK ASSESSMENTS

• Morse Fall Scale

• STEADI Fall Risk Assessment

• Observation, judgment, critical thinking with a Fall Risk Assessment tool

• JACCK AND JILL – Pediatric

• Fall Injury Risk Assessment - ABCS

DIFFERENT APPROACHES

• Hourly/Scheduled rounding

• Every patient vs Moderate to High

Risk Patients

• Fall Assessment vs Fall Assessment

PLUS Fall Injury Risk Assessment

• Adult only vs Pediatric and OB

assessments as well

MISCELLANEOUS ADDITIONS

• Safe patient handling training

• Appropriately functioning equipment

• Early and progressive mobility if appropriate

• Educate on activity level

• Demonstrate (teach back) use of call light

• Transfer time-out

• List of High Risk medications

• All employees allowed and expected to assist high risk patients if needed

STORYBOARD COMMON THEMES

• All CAHs reduced their falls between 15% and 100%

• Common themes across storyboards were:

• Safety Culture

• Front line staff participation in program development

• Up front and ongoing education for staff

• Interdisciplinary Falls Team

• Root Cause Analysis

• Daily Focus on Falls prevention at Safety Huddles

• Review each event after it happens

• Hardwire behavior

STORYBOARD METHODS

• Safety Trumps Privacy initiative

• Pharmacy review of high risk medications

• Supervisor oversight of admission fall risk assessment completion

• Environment – night lights, beds against walls

• Equipment – floor mats, wheelchair anti-tip bars

• Post fall huddle

• Purposeful Rounding (Person, Plan, Position, Personal Hygiene, Pain, Presence) The 6 P’s

• Purposeful Rounding Built into EHR

STORYBOARD METHODS

• Rounding clocks

• Education blitz for proper bed alarm settings

• Educate ancillary departments on bed alarm activation

• Report high risk patients at change of shift huddle

• “Days without a fall” awareness

• Stock gait belts in bedside table for convenient use

• Equipment availability and additional training

• Visual cues to identify high risk patients

STORYBOARD METHODS

• No Pass Zone

• Good Catch Program

• Site visits by MHA or other Falls Experts

• RCA on 100% of falls with injury

• Various Falls Risk assessments

• System-wide Harms Committee

• Frontline staff work group reviewed falls data and completed gap analysis

QUESTIONS??????

Group Discussion