A Multidisciplinary Fall Prevention Approach on a 42-bed Acute Care Unit

The fall with-injury rate decreased to 0.31/1,000 patient days or an 80% reduction, a 60% increase in reported near misses or assisted falls, and a new 93-day record without an injurious fall. Patients are safer today because of the collaborative process and the culture of safety we established, even through the Covid-19 pandemic. Patient falls can lead to injury, increased length of stay, morbidity, and mortality. A 42-bed Medical Surgical Unit in a small community hospital had a high fall injury rate despite generalized system fall prevention practices. The define, measure, analyze, improve, and control (DMAIC) process improvement framework was utilized for a multidisciplinary approach to understanding falls with injury, implement basic improvement strategies, and drive quality outcomes within a culture of prioritized patient safety. This DMAIC project has relevant clinical, project management and process improvement shared learnings that frontlines, leaders, and process improvement partners could redeploy or learn from.

Problem: Reduce the fall with-injury rate from 1.58/1,000 patient days by 20% to 1.26/1,000 patient days within 3 months of the final intervention application. Then align to, or below, the system fall with the injury goal of 0.48/1,000 patient days by the end of the fiscal year

Measurement: The team reviewed and analyzed 37 data elements overlaid with a detailed current state process map with 16 themed pain points. Various measurement tools include run charts, manual audits for time, automated response time reports, internal incident reporting details, and an internal Inpatient Fall Dashboard

Analysis: The team discussed data results and process map opportunities for improvement together. Clarity was provided as needed for consensus. The team then used a Root Cause Affinity exercise to vote on the top 4 root causes. The team then completed an Impact/Effort Grid Matrix for solutions with 48 action items

Implementation: Created and instituted a Post-Fall Tool and Debrief Huddle; reset expectations for Bedside Shift Report, alarm call light response time, proactive therapy and nursing rounding and safety checks, and patient whiteboard utilization; generated and delivered fall prevention education, initiated fall bundle audits, and optimizing and exchanging technology without an easy button

Clinical Quality Specialist at UCHealth
Clinical Quality Specialist – UCHealth

Speaker Type: Poster Presentations On-Demand