Patient Safety--Falls

“So you know something about falls, Curmudge?”

“I am familiar with their effects, Jaded Julie. Mrs. Curmudgeon has a propensity to be vertically challenged.”

“Propensity? Vertically challenged? That must mean that she falls a lot.”

“Regrettably, she tends to fall on her face. She sometimes gets a giant hematoma over one eye or the other. Her face gets discolored, her eye is swollen shut, and she looks like a battered woman. And I get an undeserved reputation as a wife-beater. Surely we can do a better job of shielding our patients from falls than I have done for my wife.”

“We are, Curmudge. Our Fall Assessment and Prevention Kaizen Event in the summer of 2008 was classic Lean. We had a great team that represented a cross-section of disciplines in the hospital. They broke into two simultaneous events to tackle the fall assessment process and standard work for use of fall prevention tools and techniques. Each collected data and considered the present state and desired future state for patient fall assessment and prevention.”

“So what did the data on the present state tell us, Julie?”

“For our three hospitals, the overall fall rate was 3.77 falls per 1,000 patient days. That’s not too bad, but experiencing a fall every 34 hours shows the need for improvement. We’d like to get the fall rate down to 3.4 in 2009 and 2 in 2011.”

“After evaluating our present state, I presume that the team developed a path forward.”

“They created a fall assessment tool for identifying those patients at high risk of falling and also a plan for communicating the tool to our nurses. Standard work was developed for implementing fall prevention techniques and for post-fall assessment and care. A Fall Alert Team was created to respond to all falls within the hospital. The fall prevention protocol will include 1-hour checks of all patients and 30-minute checks for fall-risk patients. The checks will include the Four Ps (Pain, Potty, Position, and Prevention). Some patients will need 15-minute checks or 1:1 care. Technical aids, such as motion sensors, will also be utilized.”

“Other hospitals have most likely tackled the problem of patient falls. Has their work been described in the open literature?”

“You know full well that it has, Curmudge. Ascension Health, the largest not-for-profit health care system in the country, has conducted an extensive program to prevent falls and eliminate falls with injury (1). Their key strategies were:
Assessment and re-assessment of patient risk factors for falls,
Visual identification of patients at high risk,
Communication of patient fall risk status, and
Education of patients, families, and staff about fall prevention.”

“The paper reminds us that falls are the leading cause of injury deaths among adults aged 65 and older. Our team undoubtedly benefitted from the report of Ascension’s experience.”

“Curmudge, our hospitals are making good progress in minimizing inpatient falls, but what can we do to help your ‘vertically challenged’ wife?”

“Maybe I can convince her that wearing a gait belt is the latest fashion. Then I can grab it when I see her start to fall.”

“Yeah, Curmudge. And you’ll both end up in a pile on the sidewalk.”

Affinity’s Kaizen Curmudgeon

(1) Lancaster, A.D., Preventing Falls and Eliminating Injury at Ascension Health The Joint Commission Journal on Quality and Patient Safety, vol. 33, no. 7:367-375 (July 2007).