Fall Prevention

Program
Lisa Morrill
Ferris State University

Outline

Identify the need for change

Review Literature
Develop working groups and fall prevention plan
Discuss leadership traits and change strategy
Outline implementation concepts
Review, evaluate and support effective change

Identification of Need
Event reporting
National Patient Safety Goals-9
Insurances not reimbursing additional financial costs
from fall
Patient quality and safety goals
Scope and Standards of Nursing Practice

Literature Review
Fall Prevention in Acute Care Hospitals-Dykes, P., Carroll,
D., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., Meltzer, S.,
Tsurikova, R., Luyov, L. & Middleton, B. Results shows the use
of a fall prevention tool kit in hospital units compared with
usual care significantly reduced rate of falls.
Reducing the Patient Fall Rate in a Rural Health SystemWayland, L., Holt, L., Sewell, S., Bird, J., Edelman, L. shows
the evaluation and improvement process resulted in reduced
patient falls.
Interventions for the prevention of falls in older adults:
systematic review and meta-analysis of randomized
clinical trials-Chang, J., Morton, S., Rubenstein, L., Mojica,
W., Maglione, M., Suttorp, M., Roth, E., Shekelle, P. Results
show Interventions to prevent falls in older adults are effective
in reducing both the risk of falling and the monthly rate of
falling

Stakeholders

The patient
Patient family
Front line staff
Management staff
Organization

Transformational Leader
A style of leadership in which the leader identifies the
needed change, creates a vision to guide the change through
inspiration, and executes the change with the commitment
(Marshall, 2011. p. 3)
Awaken, Envision and Rearchitecting (Roussel, 2013).
Focusing on the welfare of the individual and humanizing the
high tech work environment (Roussel, 2013, p. 738).
Empower and trust (Roussel, 2013).

Change Process
Increase the sense of urgency
Build guiding teams
Get the vision right
(Cohen, 2005)

Fall Prevention Team

Administration
Initial Fall Committee
Expanded Fall Committee
Communicator
Educator
Clinical Staff

Interventions

Risk assessment and reassessments

Hourly rounding
Low bed
Patient identification-slippers, wrist band, locator badge
Bed and chair alarms
Gait belts
Bathroom assistance and toilet regimen
Lifting equipment
Staff, patient and family education
Medication review
Patient location

Additional Resources
Equipment needs
gait belts
lifts
assistive devices
low beds
bed and chair alarms
patient identifiers

Implementation

Go live date
Superusers
Elevation of communication
Identification of inefficiencies
Identification of barriers
Rounding and spot checks
Short term wins

Evaluation and Measurement

Care giver feedback
Rounding
Data comparison and benchmarking

Budget Thoughts
Operating budget costs for new equipment
Staffing budget costs for team meetings, superusers
and additional staff during go live
Request additional FTE for nurse aid to patient ratio
of 1:10

Culture Change

Maintain the urgency

Show commitment and visibility
Be patient and persistent
Celebrate successes
Expectation of care
Continual reassessment, monitoring and process
improvement

References
American Nurses Association. (2009). Nursing administration: Scope and
standards of practice. Silver Spring, MD: American Nurses Association
Boushon B, Nielsen G, Quigley P, Rutherford P, Taylor J, Shannon D, Rita S.
(2012). How-to Guide: Reducing Patient Injuries from Falls. Cambridge, MA:
Institute for Healthcare Improvement. Retrieved from: www.IHI.org.
Chang, J., Morton, S., Rubenstein, L., Mojica, W., Maglione, M., Suttorp, M.,
Roth, E., Shekelle, P. (2004). Interventions for the prevention of falls in older
adults: systematic review and meta-analysis of randomized clinical trials. BMJ.
328(7441):680.
Cohen, D. (2005). The heart of change field guide: Tools and tactics for
leading change in your organization. Harvard Business School Press. Boston,
Ma.
Kotter, J. (1995). Leading change. Harvard Business Review on leading
through change. United State of America.

References (cont)
Dykes, P., Carroll, D., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., Meltzer, S., Tsurikova,
R., Luyov, L. & Middleton, B. (2010). Fall prevention in acute care hospitals. Jama.
304(17):1912-1918.
Joint Commission. (2013). National patient safety goals. Retrieved from
http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_OME.pdf
Marshall, E. (2011). Transformational leadership in nursing: From expert clinician to
influential leader. (1st ed.). New York: Springer Publishing Company, LLC.
Pearson,K., Coburn, A. (2011). Evidence-based Falls Prevention in Critical Access
Hospitals. Flex Monitoring Team. 24. Retrieved from:
http://flexmonitoring.org/documents/PolicyBrief24_Falls-Prevention.pdf
Roussel, L. (2013). Management and leadership for nurse administrators. Jones & Bartlett
Learning. Burlington, Ma.
Wayland, L., Holt, L., Sewell, S., Bird, J., Edelman, L. (2010). Reducing the patient fall rate
in a rural health system. Journal for Healthcare Quality. 32(2). p. 9-15.